Provider Demographics
NPI:1154705382
Name:MOORE, JASON OTIS
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:OTIS
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2607 CADDO ST. - STE. 6
Mailing Address - Street 2:
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71923-5307
Mailing Address - Country:US
Mailing Address - Phone:870-230-8217
Mailing Address - Fax:870-230-8201
Practice Address - Street 1:500 W. AVE E ST.
Practice Address - Street 2:
Practice Address - City:HOPE
Practice Address - State:AR
Practice Address - Zip Code:71801
Practice Address - Country:US
Practice Address - Phone:870-773-0700
Practice Address - Fax:870-773-0705
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR226648795Medicaid