Provider Demographics
NPI:1285001487
Name:HALLAM, JENNIFER LYNNE (MPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNNE
Last Name:HALLAM
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNNE
Other - Last Name:BUGG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:1100 DIVISION ST STE 3
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE GROVE
Mailing Address - State:AR
Mailing Address - Zip Code:72753-5501
Mailing Address - Country:US
Mailing Address - Phone:479-334-0014
Mailing Address - Fax:479-334-0013
Practice Address - Street 1:1100 DIVISION ST STE 3
Practice Address - Street 2:
Practice Address - City:PRAIRIE GROVE
Practice Address - State:AR
Practice Address - Zip Code:72753-5501
Practice Address - Country:US
Practice Address - Phone:479-334-0014
Practice Address - Fax:479-334-0013
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR40312251P0200X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics