Healthcare Provider Details

I. General information

NPI: 1063688232
Provider Name (Legal Business Name): JESS C PARKER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2008
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 S UTICA AVE
TULSA OK
74104-4012
US

IV. Provider business mailing address

PO BOX 8099
JONESBORO AR
72403-8099
US

V. Phone/Fax

Practice location:
  • Phone: 918-579-8344
  • Fax:
Mailing address:
  • Phone: 870-932-4211
  • Fax: 870-931-9141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCTP000079
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: