Provider Demographics
NPI:1396974838
Name:FUNDERBURG, JEREMY C
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:C
Last Name:FUNDERBURG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 S JEFFERSON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-5900
Mailing Address - Country:US
Mailing Address - Phone:870-862-7984
Mailing Address - Fax:870-863-5154
Practice Address - Street 1:217 S JEFFERSON AVE STE 100
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-5900
Practice Address - Country:US
Practice Address - Phone:870-862-7984
Practice Address - Fax:870-863-5154
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator