Basic Information
| Provider Information | |||||||||
| NPI: | 1659556090 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOUST | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | SUZANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 413 W TYLER AVE | ||||||||
| Address2: | |||||||||
| City: | WEST MEMPHIS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723014149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707331200 | ||||||||
| FaxNumber: | 8707323269 | ||||||||
| Practice Location | |||||||||
| Address1: | 413 W TYLER AVE | ||||||||
| Address2: | |||||||||
| City: | WEST MEMPHIS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723014149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707331200 | ||||||||
| FaxNumber: | 8707323269 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2008 | ||||||||
| LastUpdateDate: | 03/03/2009 | ||||||||
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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 | 225200000X | PTA 1692 | AR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 145523721 | 05 | AR | MEDICAID |