Provider Demographics
NPI:1013595420
Name:LUSTER, JERRICA LACEY (APRN-PMHNP)
Entity Type:Individual
Prefix:
First Name:JERRICA
Middle Name:LACEY
Last Name:LUSTER
Suffix:
Gender:F
Credentials:APRN-PMHNP
Other - Prefix:
Other - First Name:JERRICA
Other - Middle Name:
Other - Last Name:BALLANCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1848
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-1841
Mailing Address - Country:US
Mailing Address - Phone:479-437-3449
Mailing Address - Fax:479-243-0285
Practice Address - Street 1:3604 CENTRAL AVE STE D
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6458
Practice Address - Country:US
Practice Address - Phone:888-710-8220
Practice Address - Fax:479-243-0285
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR214728363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health