Provider Demographics
NPI:1396145850
Name:JUMPING JELLY BEANS PEDIATRIC THERAPY
Entity type:Organization
Organization Name:JUMPING JELLY BEANS PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:870-919-0274
Mailing Address - Street 1:2319 E MATTHEWS AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4415
Mailing Address - Country:US
Mailing Address - Phone:870-919-0274
Mailing Address - Fax:870-277-4335
Practice Address - Street 1:2319 E MATTHEWS AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4415
Practice Address - Country:US
Practice Address - Phone:870-919-0274
Practice Address - Fax:870-277-4335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-02
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT 2329225X00000X
ARSP 2878235Z00000X
ARSP 1873235Z00000X
ARPT 3047225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145147721Medicaid
AR180139721Medicaid
AR180284721Medicaid
AR167155721Medicaid