Provider Demographics
NPI:1184198657
Name:BANKS, JARESSA
Entity Type:Individual
Prefix:
First Name:JARESSA
Middle Name:
Last Name:BANKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 E UNION AVE
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:AR
Mailing Address - Zip Code:72370-3235
Mailing Address - Country:US
Mailing Address - Phone:870-563-1331
Mailing Address - Fax:
Practice Address - Street 1:315 E UNION AVE
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:AR
Practice Address - Zip Code:72370-3235
Practice Address - Country:US
Practice Address - Phone:870-563-1331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR229765795Medicaid