Provider Demographics
NPI:1275562688
Name:DOUGLAS, JERRE (RNP)
Entity Type:Individual
Prefix:
First Name:JERRE
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:RNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 KILLOUGH RD N
Mailing Address - Street 2:
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396
Mailing Address - Country:US
Mailing Address - Phone:870-238-8707
Mailing Address - Fax:870-238-8711
Practice Address - Street 1:1901 KILLOUGH RD N
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396
Practice Address - Country:US
Practice Address - Phone:870-238-8707
Practice Address - Fax:870-238-8711
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP01329363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5S675Medicare ID - Type Unspecified