1649059312 NPI number — VIRGINIA JENELLE NICKERSON SLP-A

Table of content: VIRGINIA JENELLE NICKERSON SLP-A (NPI 1649059312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649059312 NPI number — VIRGINIA JENELLE NICKERSON SLP-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICKERSON
Provider First Name:
VIRGINIA
Provider Middle Name:
JENELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SLP-A
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649059312
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3117 PARTIPILO ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNTAIN HOME
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72653-5855
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-206-4555
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2465 RODEO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN HOME
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72653-4501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-206-4555
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/22/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2355S0801X , with the licence number:  202372 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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