Provider Demographics
NPI:1053553024
Name:WHITEHEAD, JAIME LYN (APRN)
Entity type:Individual
Prefix:MRS
First Name:JAIME
Middle Name:LYN
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:870-347-3492
Practice Address - Street 1:400 HIGHWAY 64 E
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:AR
Practice Address - Zip Code:72006-5150
Practice Address - Country:US
Practice Address - Phone:870-347-2508
Practice Address - Fax:870-347-5556
Is Sole Proprietor?:No
Enumeration Date:2009-04-06
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006998363LF0000X, 363LF0000X
ARA03255363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100178850Medicaid
AR179377758Medicaid
AR179377758Medicaid
AR57297Medicare PIN
AR5V209Medicare PIN
AR5V2097297Medicare PIN
KYK032560Medicare PIN