Healthcare Provider Details

I. General information

NPI: 1568669844
Provider Name (Legal Business Name): JERI LOU FARABOUGH SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BRADLEY STREET
STAR CITY AR
71667
US

IV. Provider business mailing address

3655 HILLCREST RD
DUMAS AR
71639-9428
US

V. Phone/Fax

Practice location:
  • Phone: 870-628-4112
  • Fax:
Mailing address:
  • Phone: 870-263-4079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number614
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: