Basic Information
| Provider Information | |||||||||
| NPI: | 1477918738 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REAGAN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 83 | ||||||||
| Address2: | |||||||||
| City: | CORNING | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724220083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708573334 | ||||||||
| FaxNumber: | 8708579934 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 COLONIAL DR | ||||||||
| Address2: | |||||||||
| City: | WALNUT RIDGE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724761410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708865507 | ||||||||
| FaxNumber: | 8078865632 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2015 | ||||||||
| LastUpdateDate: | 04/26/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A004551 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 212613758 | 05 | AR | MEDICAID |