Healthcare Provider Details

I. General information

NPI: 1588972723
Provider Name (Legal Business Name): MARY LOUGENE PORTER-GORDON MHPP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

661 ADDISON DR
WYNNE AR
72396-1602
US

IV. Provider business mailing address

2707 BROWNS LN
JONESBORO AR
72401-7213
US

V. Phone/Fax

Practice location:
  • Phone: 870-238-1135
  • Fax: 870-238-1139
Mailing address:
  • Phone: 870-972-4939
  • Fax: 870-972-4911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: