Healthcare Provider Details

I. General information

NPI: 1487292991
Provider Name (Legal Business Name): JESSICA MCCALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 04/20/2020
Certification Date: 04/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 VENABLE LN STE 200
MONROE LA
71203-2028
US

IV. Provider business mailing address

PO BOX 9178
RUSSELLVILLE AR
72811-9178
US

V. Phone/Fax

Practice location:
  • Phone: 501-492-0099
  • Fax:
Mailing address:
  • Phone: 855-498-6767
  • Fax: 479-968-1673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number116496
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number212195
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: