Provider Demographics
NPI:1063717106
Name:JACKIE CHEATHAM
Entity type:Organization
Organization Name:JACKIE CHEATHAM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-291-1898
Mailing Address - Street 1:907 AR HWY 56
Mailing Address - Street 2:PO BOX 261
Mailing Address - City:CALICO ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72519
Mailing Address - Country:US
Mailing Address - Phone:870-291-1898
Mailing Address - Fax:
Practice Address - Street 1:907 AR HWY 56
Practice Address - Street 2:
Practice Address - City:CALICO ROCK
Practice Address - State:AR
Practice Address - Zip Code:72519
Practice Address - Country:US
Practice Address - Phone:870-291-1898
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-21
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR204333300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333300000XSuppliersEmergency Response System Companies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR204OtherEMERGENCY MEDICAL SERVICELLICENSE