Provider Demographics
NPI:1407143662
Name:JERRY, JARROD (APN)
Entity Type:Individual
Prefix:
First Name:JARROD
Middle Name:
Last Name:JERRY
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 476
Mailing Address - Street 2:110 N. BROADVIEW STREET
Mailing Address - City:GREENBRIER
Mailing Address - State:AR
Mailing Address - Zip Code:72058-0476
Mailing Address - Country:US
Mailing Address - Phone:501-679-3551
Mailing Address - Fax:
Practice Address - Street 1:110 N BROADVIEW ST
Practice Address - Street 2:
Practice Address - City:GREENBRIER
Practice Address - State:AR
Practice Address - Zip Code:72058-9475
Practice Address - Country:US
Practice Address - Phone:501-679-3551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03531363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily