Provider Demographics
NPI:1992081491
Name:BARHAM, JODY A (APN)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:A
Last Name:BARHAM
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4323 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-1515
Mailing Address - Country:US
Mailing Address - Phone:870-773-0700
Mailing Address - Fax:870-773-0705
Practice Address - Street 1:1205 E 35TH ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-2746
Practice Address - Country:US
Practice Address - Phone:870-216-0080
Practice Address - Fax:870-216-0096
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03610363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARA003610OtherLICENSE