Provider Demographics
NPI:1225348980
Name:CHEATHAM, JACKIE LEON (EMT)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:LEON
Last Name:CHEATHAM
Suffix:
Gender:M
Credentials:EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 261
Mailing Address - Street 2:907 AR HWY 56
Mailing Address - City:CALICO ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72519-0261
Mailing Address - Country:US
Mailing Address - Phone:870-421-9494
Mailing Address - Fax:
Practice Address - Street 1:907 AR HWY 56
Practice Address - Street 2:
Practice Address - City:CALICO ROCK
Practice Address - State:AR
Practice Address - Zip Code:72519-0261
Practice Address - Country:US
Practice Address - Phone:870-421-9494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR16847146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic