Provider Demographics
NPI:1407260888
Name:EVANS, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 SE LINDSEY ST
Mailing Address - Street 2:
Mailing Address - City:HOXIE
Mailing Address - State:AR
Mailing Address - Zip Code:72433-2224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:925 HIGHWAY 25
Practice Address - Street 2:
Practice Address - City:STRAWBERRY
Practice Address - State:AR
Practice Address - Zip Code:72469-8570
Practice Address - Country:US
Practice Address - Phone:870-283-4589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4218225200000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No171M00000XOther Service ProvidersCase Manager/Care Coordinator