Individual
JANA KAYE WITHERSPOON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
306 BROADWAY BLVD, PORTLAND, TX 78374-1301
(870) 577-3274
Mailing address
306 BROADWAY BLVD, PORTLAND, TX 78374-1301
(870) 577-3274
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
Primary
227133
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
080581114
DRIVERS LICENSE
CO
Enumeration date
05/01/2020
Last updated
05/01/2020
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