Provider Demographics
NPI:1720771330
Name:EDWARDS, JESSE
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:EDWARDS
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 1:4301 W MARKHAM ST # 783
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-7101
Mailing Address - Country:US
Mailing Address - Phone:501-686-8000
Mailing Address - Fax:501-526-5148
Practice Address - Street 1:1125 N COLLEGE AVE # 100
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1908
Practice Address - Country:US
Practice Address - Phone:479-713-8630
Practice Address - Fax:479-713-8639
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT4623225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist