Healthcare Provider Details

I. General information

NPI: 1013493675
Provider Name (Legal Business Name): JEFFREY HOMSTAD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5532 JFK BLVD
NORTH LITTLE ROCK AR
72116-6708
US

IV. Provider business mailing address

1701 DAVE WARD DR LOT 258
CONWAY AR
72034-6900
US

V. Phone/Fax

Practice location:
  • Phone: 501-588-3211
  • Fax:
Mailing address:
  • Phone: 501-588-3211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA4343
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: