Provider Demographics
NPI:1740819135
Name:ICENHOWER, JERRAMY (NP)
Entity type:Individual
Prefix:
First Name:JERRAMY
Middle Name:
Last Name:ICENHOWER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4196 HIGHWAY 62 412 STE A
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:AR
Mailing Address - Zip Code:72542-8002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1016 N FOURCHE AVE
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72126-8545
Practice Address - Country:US
Practice Address - Phone:501-238-1284
Practice Address - Fax:501-468-0469
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-07
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR123834363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily