Basic Information
| Provider Information | |||||||||
| NPI: | 1861143364 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EZZELDIN | ||||||||
| FirstName: | JACKLYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 251970 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722251970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016668686 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6601 W 12TH ST | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722041513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016668686 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2022 | ||||||||
| LastUpdateDate: | 01/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0807X | R04563 | AR | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Child & Adolescent | 163WP0809X | R04563 | AR | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult | 163WP0808X | R04563 | AR | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.