Provider Demographics
NPI:1548665748
Name:WOODRUFF, TRAVIS E SR (MHPP)
Entity type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:E
Last Name:WOODRUFF
Suffix:SR
Gender:M
Credentials:MHPP
Other - Prefix:MR
Other - First Name:TRAVIS
Other - Middle Name:E
Other - Last Name:WOODRUFF
Other - Suffix:SR
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1815 PLEASANT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7870
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:1704 HWY 69
Practice Address - Street 2:
Practice Address - City:TRUMANN
Practice Address - State:AR
Practice Address - Zip Code:72472
Practice Address - Country:US
Practice Address - Phone:870-483-4003
Practice Address - Fax:870-483-4009
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR170145795Medicaid