Provider Demographics
NPI:1952531097
Name:HAVARD, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HAVARD
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 1:360 OUACHITA 69
Mailing Address - Street 2:
Mailing Address - City:SMACKOVER
Mailing Address - State:AR
Mailing Address - Zip Code:71762-9607
Mailing Address - Country:US
Mailing Address - Phone:870-807-4087
Mailing Address - Fax:
Practice Address - Street 1:360 OUACHITA 69
Practice Address - Street 2:
Practice Address - City:SMACKOVER
Practice Address - State:AR
Practice Address - Zip Code:71762-9607
Practice Address - Country:US
Practice Address - Phone:870-807-4087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A541224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR177298721Medicaid