Basic Information
| Provider Information | |||||||||
| NPI: | 1376539288 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FANT | ||||||||
| FirstName: | JERRI | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 55050 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722155050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019063000 | ||||||||
| FaxNumber: | 5019076522 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 SPRINGHILL DRIVE | ||||||||
| Address2: | |||||||||
| City: | NORTH LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019063000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2005 | ||||||||
| LastUpdateDate: | 03/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | E2749 | AR | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 146285001 | 05 | AR | MEDICAID |