Provider Demographics
NPI:1932583747
Name:KALLSNICK, JORDAN BROOKE
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:BROOKE
Last Name:KALLSNICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 LAKE OAK DRIVE
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72501
Mailing Address - Country:US
Mailing Address - Phone:870-595-4388
Mailing Address - Fax:
Practice Address - Street 1:3150 HARRISON ST
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-7515
Practice Address - Country:US
Practice Address - Phone:870-793-4464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD13248183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist