Healthcare Provider Details

I. General information

NPI: 1528277720
Provider Name (Legal Business Name): JENNIFER MARIE KACZMARCZYK BS, MHPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 W TYLER AVE
WEST MEMPHIS AR
72301-4149
US

IV. Provider business mailing address

1618 LATOURETTE LANE APARTMENT C
JONESBORO AR
72404
US

V. Phone/Fax

Practice location:
  • Phone: 870-733-1200
  • Fax: 870-732-3269
Mailing address:
  • Phone: 614-638-5212
  • Fax: 870-732-3269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: