# ST JOHNS CLINIC INC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** SJC-BERRYVILLE FAMILY PRACTICE
- **Organization subpart:** No

## Provider details

- **NPI number:** 1447323399
- **Authorized official:** VICKIE JENKINS (PROVIDER ENROLLMENT COORDINATOR)
- **Authorized official phone:** (417) 829-4264

## Contact information

- **Practice address:** 613 ORCHARD DR, BERRYVILLE, AR 72616-5013
- **Practice address phone:** (870) 423-7171
- **Practice address fax:** (870) 423-1032
- **Mailing address:** PO BOX 2580, SPRINGFIELD, MO 65801-2580
- **Mailing address phone:** (417) 829-4620
- **Mailing address fax:** (417) 829-4316

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | C4889 | AR | Yes |

## Other

- **Enumeration date:** 11/16/2006
- **Last updated:** 06/27/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 150959002 | — | AR |
| 01 | — | CR0464 | TRAVELERS/RR MEDICARE \# | AR |