Provider Demographics
NPI:1982019592
Name:DAVIS, TELISA (QBHP)
Entity Type:Individual
Prefix:
First Name:TELISA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:QBHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 FOREST HOME RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5320
Mailing Address - Country:US
Mailing Address - Phone:866-972-1268
Mailing Address - Fax:
Practice Address - Street 1:2005 MCLAIN ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-3662
Practice Address - Country:US
Practice Address - Phone:870-495-1990
Practice Address - Fax:870-495-1994
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR202882795Medicaid