Healthcare Provider Details

I. General information

NPI: 1184711236
Provider Name (Legal Business Name): JAY KINCANNON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 03/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS WAY # 653
LITTLE ROCK AR
72202-3500
US

IV. Provider business mailing address

1 CHILDRENS WAY # 653
LITTLE ROCK AR
72202-3500
US

V. Phone/Fax

Practice location:
  • Phone: 501-364-1100
  • Fax: 501-526-5148
Mailing address:
  • Phone: 501-364-1100
  • Fax: 501-526-5148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberC-6844
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: