Provider Demographics
NPI:1417141920
Name:PETTUS, JAMIE KEITH (LPN)
Entity Type:Individual
Prefix:MR
First Name:JAMIE
Middle Name:KEITH
Last Name:PETTUS
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 HIGHWAY 67 BLDG 70
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-8909
Mailing Address - Country:US
Mailing Address - Phone:501-315-3344
Mailing Address - Fax:501-303-3186
Practice Address - Street 1:6701 HIGHWAY 67 BLDG 70
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-8909
Practice Address - Country:US
Practice Address - Phone:501-315-3344
Practice Address - Fax:501-303-3186
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL38028164W00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No164W00000XNursing Service ProvidersLicensed Practical Nurse