Healthcare Provider Details

I. General information

NPI: 1629784665
Provider Name (Legal Business Name): JEREMCIA MCDANIEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2023
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6210 BASELINE RD
LITTLE ROCK AR
72209-4728
US

IV. Provider business mailing address

2124 LABETTE MANOR DR APT Y28
LITTLE ROCK AR
72205-7339
US

V. Phone/Fax

Practice location:
  • Phone: 501-265-0302
  • Fax: 501-265-0302
Mailing address:
  • Phone: 870-821-1418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: