Basic Information
| Provider Information | |||||||||
| NPI: | 1346293974 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADKISSON | ||||||||
| FirstName: | JARROD | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 6430 | ||||||||
| Address2: | 2400 S. 48TH | ||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797502020 | ||||||||
| FaxNumber: | 4797508967 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 S. 48TH | ||||||||
| Address2: | |||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797502020 | ||||||||
| FaxNumber: | 4797508967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 11/21/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | C-8412 | AR | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 8168000000 | 01 | AR | QUALCHOICE QCA | OTHER | 135993001 | 05 | AR | MEDICAID | 7463260 | 01 | AR | AETNA | OTHER | BLUE CROSS | 01 | AR | 5L000 | OTHER |