Basic Information
| Provider Information | |||||||||
| NPI: | 1588967129 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAULKNER | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MHPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 VILLAGE DR | ||||||||
| Address2: | APT 20 | ||||||||
| City: | ARKADELPHIA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719232932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704513979 | ||||||||
| FaxNumber: | 8702308201 | ||||||||
| Practice Location | |||||||||
| Address1: | 2506 COUNTRY CLUB RD | ||||||||
| Address2: | |||||||||
| City: | ARKADELPHIA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719232930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702308217 | ||||||||
| FaxNumber: | 8702308201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2010 | ||||||||
| LastUpdateDate: | 12/20/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.