Provider Demographics
NPI:1275070500
Name:NORMAN III, JIMMY
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:NORMAN III
Suffix:
Gender:M
Credentials:
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 1589
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018-1589
Mailing Address - Country:US
Mailing Address - Phone:501-303-3105
Mailing Address - Fax:
Practice Address - Street 1:242 SHAKE RAG RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:AR
Practice Address - Zip Code:72031-6629
Practice Address - Country:US
Practice Address - Phone:501-303-3105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2011156101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor