Provider Demographics
NPI:1073368536
Name:TRAVER, JALISHA
Entity type:Individual
Prefix:
First Name:JALISHA
Middle Name:
Last Name:TRAVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 ROBERTS DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655-5723
Mailing Address - Country:US
Mailing Address - Phone:870-367-2461
Mailing Address - Fax:
Practice Address - Street 1:529 S BORCHARDT ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-4603
Practice Address - Country:US
Practice Address - Phone:870-367-2461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator