Provider Demographics
NPI:1629784665
Name:MCDANIEL, JEREMCIA
Entity Type:Individual
Prefix:
First Name:JEREMCIA
Middle Name:
Last Name:MCDANIEL
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 1:2124 LABETTE MANOR DR APT Y28
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-7339
Mailing Address - Country:US
Mailing Address - Phone:870-821-1418
Mailing Address - Fax:
Practice Address - Street 1:6210 BASELINE RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-4728
Practice Address - Country:US
Practice Address - Phone:501-265-0302
Practice Address - Fax:501-265-0302
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator