Provider Demographics
NPI:1881293975
Name:ANDERSON, JEANA CORLEEN (MMT, CLT, CNHP)
Entity type:Individual
Prefix:
First Name:JEANA
Middle Name:CORLEEN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MMT, CLT, CNHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 CHRISTMAS DR
Mailing Address - Street 2:
Mailing Address - City:CASA
Mailing Address - State:AR
Mailing Address - Zip Code:72025-7514
Mailing Address - Country:US
Mailing Address - Phone:501-233-6269
Mailing Address - Fax:
Practice Address - Street 1:2621 W MAIN ST STE 9
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2551
Practice Address - Country:US
Practice Address - Phone:501-690-3306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR8302225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist