Provider Demographics
NPI:1316755416
Name:WOOTEN, SAMUEL PARKER
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:PARKER
Last Name:WOOTEN
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 1:5005 YUKON DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-5173
Mailing Address - Country:US
Mailing Address - Phone:870-941-1664
Mailing Address - Fax:870-930-9336
Practice Address - Street 1:151 SOUTHWEST DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5828
Practice Address - Country:US
Practice Address - Phone:870-932-0090
Practice Address - Fax:870-930-9336
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist