Provider Demographics
NPI:1720522543
Name:GEREN, JESSA MAY
Entity Type:Individual
Prefix:
First Name:JESSA
Middle Name:MAY
Last Name:GEREN
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 1:8107 S 35TH TER
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72908-8701
Mailing Address - Country:US
Mailing Address - Phone:479-202-1850
Mailing Address - Fax:
Practice Address - Street 1:1109 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-3363
Practice Address - Country:US
Practice Address - Phone:479-202-1850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant