1902244908 NPI number — JOSHUA WAYNE EVERETT LCSW, RPT, RIST

Table of content: JESSICA KOPPEN ARNP (NPI 1720515836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902244908 NPI number — JOSHUA WAYNE EVERETT LCSW, RPT, RIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVERETT
Provider First Name:
JOSHUA
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW, RPT, RIST
Provider Gender Code:
M

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:
1902244908
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1815 PLEASANT GROVE ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-933-6886
Provider Business Mailing Address Fax Number:
870-933-9395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1905 LINWOOD DR STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARAGOULD
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-565-7201
Provider Business Practice Location Address Fax Number:
870-359-6094
Provider Enumeration Date:
06/12/2013

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 7984-C , 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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