Provider Demographics
NPI:1154489581
Name:COOMBE-MOORE, JACKIE (MD)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:COOMBE-MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:34 MASTERS PLACE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113
Mailing Address - Country:US
Mailing Address - Phone:501-505-8900
Mailing Address - Fax:501-505-8902
Practice Address - Street 1:COUNSELING ASSOCIATES, INC
Practice Address - Street 2:8 HOSPITAL DRIVE
Practice Address - City:MORRILTON
Practice Address - State:AR
Practice Address - Zip Code:72110
Practice Address - Country:US
Practice Address - Phone:501-505-8900
Practice Address - Fax:501-505-8902
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC82912084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR122013001Medicaid
AR55779Medicare ID - Type Unspecified
ARF35975Medicare UPIN