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General NPI Number Information
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NPI Number | 1114807088
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Entity Type | Individual
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Provider Name | MS. JAMISEN JEWELL GAUNTT
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Gender | Female
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Dates
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Enumeration Date | 09/03/2025
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Last Update Date | 09/03/2025
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Provider Practice Location Address
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Address Line | 101 SHADY PARK LN
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City | BONO
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State | AR
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Zip | 72416-9581
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Country | US
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Telephone | 870-586-3368
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Fax |
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Provider Business Mailing Address
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Address Line | 101 SHADY PARK LN
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City | BONO
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State | AR
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Zip | 72416-9581
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Country | US
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Telephone | 870-586-3368
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081P0010X
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Taxonomy Name | Pediatric Rehabilitation Medicine Physician
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License Number | 5038
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License Number State | AR
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