Provider Demographics
NPI:1841513223
Name:JACKIE COOMBE-MOORE PA
Entity type:Organization
Organization Name:JACKIE COOMBE-MOORE PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COOMBE-MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-505-8900
Mailing Address - Street 1:680 HOGAN LN
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-8131
Mailing Address - Country:US
Mailing Address - Phone:501-505-8900
Mailing Address - Fax:501-505-8902
Practice Address - Street 1:680 HOGAN LN
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-8131
Practice Address - Country:US
Practice Address - Phone:501-505-8900
Practice Address - Fax:501-505-8902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-12
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR11547000000OtherQCA
AR55779OtherMEDICARE PTAN
AR122013001Medicaid
AR11547000000OtherQCA