Healthcare Provider Details

I. General information

NPI: 1174942528
Provider Name (Legal Business Name): JACEY TANNER GUTHRIE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 10/14/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 N RODNEY PARHAM RD STE 202
LITTLE ROCK AR
72212
US

IV. Provider business mailing address

4200 N RODNEY PARHAM RD STE 202
LITTLE ROCK AR
72212-2460
US

V. Phone/Fax

Practice location:
  • Phone: 501-227-4323
  • Fax: 501-227-4149
Mailing address:
  • Phone: 501-227-4323
  • Fax: 501-227-4149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberE-11347
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: