Basic Information
| Provider Information | |||||||||
| NPI: | 1598027518 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ASHLOCK | ||||||||
| FirstName: | REBECCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2809 FOREST HOME RD | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724015320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669721268 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1820 CENTRAL AVE STE B | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719016898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016236000 | ||||||||
| FaxNumber: | 5016236004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2012 | ||||||||
| LastUpdateDate: | 08/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 226665795 | 05 | AR | MEDICAID |