Healthcare Provider Details

I. General information

NPI: 1275562688
Provider Name (Legal Business Name): JERRE DOUGLAS RNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 KILLOUGH RD N
WYNNE AR
72396
US

IV. Provider business mailing address

1901 KILLOUGH RD N
WYNNE AR
72396
US

V. Phone/Fax

Practice location:
  • Phone: 870-238-8707
  • Fax: 870-238-8711
Mailing address:
  • Phone: 870-238-8707
  • Fax: 870-238-8711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberP01329
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: