Provider Demographics
NPI:1881015873
Name:ROGERS, JACQUE RENEE (MHPP)
Entity Type:Individual
Prefix:
First Name:JACQUE
Middle Name:RENEE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO DRAWER 2109
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811
Mailing Address - Country:US
Mailing Address - Phone:479-967-2322
Mailing Address - Fax:479-967-2876
Practice Address - Street 1:2403 MAIN DR STE 1AND2
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-5223
Practice Address - Country:US
Practice Address - Phone:479-249-6379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-18
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR228759795Medicaid