=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336512979
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KERRY UNDERWOOD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2015
-----------------------------------------------------
Last Update Date | 03/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5401 ROGERS AVE SUITE 200
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72903-3745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-226-8403
-----------------------------------------------------
Fax | 479-250-0334
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5401 ROGERS AVE SUITE 200
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72903-3745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-226-8403
-----------------------------------------------------
Fax | 479-250-0334
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. MARY JEPPSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 479-226-8403
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | A1101002
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------