Provider Demographics
NPI:1780808196
Name:DAVIS, JIM GLENN
Entity type:Individual
Prefix:
First Name:JIM
Middle Name:GLENN
Last Name:DAVIS
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 1:502 GREENING STREET
Mailing Address - Street 2:SUITE 3C
Mailing Address - City:CAMDEN
Mailing Address - State:AR
Mailing Address - Zip Code:71701
Mailing Address - Country:US
Mailing Address - Phone:870-837-4065
Mailing Address - Fax:
Practice Address - Street 1:502 GREENING ST
Practice Address - Street 2:SUITE 3C
Practice Address - City:CAMDEN
Practice Address - State:AR
Practice Address - Zip Code:71701-3491
Practice Address - Country:US
Practice Address - Phone:870-837-4065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC00332174400000X
ARC000332367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR135850002Medicaid