Provider Demographics
NPI:1659369973
Name:HOUSEHOLDER, JEANMARIE (MD)
Entity Type:Individual
Prefix:
First Name:JEANMARIE
Middle Name:
Last Name:HOUSEHOLDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 402330
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2330
Mailing Address - Country:US
Mailing Address - Phone:479-709-7399
Mailing Address - Fax:479-709-7053
Practice Address - Street 1:1500 DODSON AVE
Practice Address - Street 2:STE 230
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-5182
Practice Address - Country:US
Practice Address - Phone:479-709-7490
Practice Address - Fax:479-709-7495
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3223207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100032950AMedicaid
AR146290001Medicaid
ARH58408Medicare UPIN
AR146290001Medicaid