Provider Demographics
NPI:1467814137
Name:MCMILLON, JAKE
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:MCMILLON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 W KINGSHIGHWAY
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-4142
Mailing Address - Country:US
Mailing Address - Phone:870-239-4076
Mailing Address - Fax:870-239-4079
Practice Address - Street 1:1015 W KINGSHIGHWAY
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-4142
Practice Address - Country:US
Practice Address - Phone:870-239-4076
Practice Address - Fax:870-239-4079
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ARE-11120207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR213955795Medicaid