=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720522543
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSA MAY GEREN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2016
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1109 FAYETTEVILLE RD
-----------------------------------------------------
City | VAN BUREN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72956-3363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-202-1850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8107 S 35TH TER
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72908-8701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-202-1850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------