Healthcare Provider Details

I. General information

NPI: 1427769025
Provider Name (Legal Business Name): GWENDOLYN JONES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 S AVALON ST
WEST MEMPHIS AR
72301-4165
US

IV. Provider business mailing address

103 S AVALON ST
WEST MEMPHIS AR
72301-4165
US

V. Phone/Fax

Practice location:
  • Phone: 870-732-1878
  • Fax: 870-702-7111
Mailing address:
  • Phone: 870-732-1878
  • Fax: 870-702-7111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: