Healthcare Provider Details

I. General information

NPI: 1538669189
Provider Name (Legal Business Name): JACOB B ADKISON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2018
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 W WALNUT ST STE 100
ROGERS AR
72756-3246
US

IV. Provider business mailing address

PO BOX 776084
CHICAGO IL
60677-6084
US

V. Phone/Fax

Practice location:
  • Phone: 417-451-4545
  • Fax: 417-451-4546
Mailing address:
  • Phone: 314-543-6979
  • Fax: 314-364-6321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018004598
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number124264
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: