Provider Demographics
NPI:1730285081
Name:JAGGERS, JOAN M (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:M
Last Name:JAGGERS
Suffix:
Gender:F
Credentials:CRNA
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 10830
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-0049
Mailing Address - Country:US
Mailing Address - Phone:479-414-3219
Mailing Address - Fax:479-301-2488
Practice Address - Street 1:10 E LOVERS LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-2831
Practice Address - Country:US
Practice Address - Phone:479-414-3219
Practice Address - Fax:479-301-2488
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC00569367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR120778701Medicaid
OK100781500AMedicaid
AR59462Medicare ID - Type Unspecified