Provider Demographics
NPI:1780019570
Name:SEBOURN, JON ROBERT SR
Entity type:Individual
Prefix:
First Name:JON
Middle Name:ROBERT
Last Name:SEBOURN
Suffix:SR
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 1:3204 E MOORE AVE
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-4826
Mailing Address - Country:US
Mailing Address - Phone:501-268-7777
Mailing Address - Fax:501-305-5009
Practice Address - Street 1:25 GAP RD
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-8679
Practice Address - Country:US
Practice Address - Phone:870-793-8900
Practice Address - Fax:870-793-8959
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL51261174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist