Basic Information
| Provider Information | |||||||||
| NPI: | 1992081491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARHAM | ||||||||
| FirstName: | JODY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4323 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718541515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707730700 | ||||||||
| FaxNumber: | 8707730705 | ||||||||
| Practice Location | |||||||||
| Address1: | 1205 E 35TH ST | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718542746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702160080 | ||||||||
| FaxNumber: | 8702160096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2011 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | A03610 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | A003610 | 01 | AR | LICENSE | OTHER |