Provider Demographics
NPI:1720215791
Name:WITHROW, JESSICA NACOLE
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:NACOLE
Last Name:WITHROW
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 1:624 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-2955
Mailing Address - Country:US
Mailing Address - Phone:870-508-1081
Mailing Address - Fax:870-508-1644
Practice Address - Street 1:7345 HIGHWAY 62 W
Practice Address - Street 2:
Practice Address - City:GASSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72635-8636
Practice Address - Country:US
Practice Address - Phone:870-435-5511
Practice Address - Fax:870-435-5513
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator