Healthcare Provider Details

I. General information

NPI: 1740819135
Provider Name (Legal Business Name): JERRAMY ICENHOWER NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 12/31/2024
Certification Date: 12/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 N FOURCHE AVE
PERRYVILLE AR
72126-8545
US

IV. Provider business mailing address

4196 HIGHWAY 62 412 STE A
HARDY AR
72542-8002
US

V. Phone/Fax

Practice location:
  • Phone: 501-238-1284
  • Fax: 501-468-0469
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number123834
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: