Provider Demographics
NPI:1902267875
Name:FAYETTEVILLE ARKANSAS HOSPITAL COMPANY LLC
Entity Type:Organization
Organization Name:FAYETTEVILLE ARKANSAS HOSPITAL COMPANY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. DIRECTOR PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:615-778-8075
Mailing Address - Fax:615-628-6877
Practice Address - Street 1:3873 N PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6286
Practice Address - Country:US
Practice Address - Phone:479-571-7070
Practice Address - Fax:479-571-7090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-18
Last Update Date:2022-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty