NPIMap

Organization Active NPI

State PF Arkansas

Doing business as Jonesboro Human Development Center

  • Intellectual and/or Developmental Disabilities Residential Treatment Facility
  • Jonesboro, AR
National Provider Identifier
1386770030
Registry record updated Aug 16, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual and/or Developmental Disabilities Residential Treatment FacilityTaxonomy code 320600000X
License
137 Issued in AR
Legal business name
STATE PF ARKANSAS
Doing business as
Jonesboro Human Development Center
Practice address
4701 Colony Dr
Jonesboro, AR 72404-9317
Phone
(870) 932-4043
Fax
(870) 932-4459
NPI assigned
Feb 26, 2007
Last updated
Aug 16, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 16, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Theresia Diane Keith
Title
Superintendent
Phone
(870) 932-4043

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual and/or Developmental Disabilities Residential Treatment Facility 320600000X 137 AR Primary

Addresses

Primary practice location

4701 Colony Dr
Jonesboro, AR 72404-9317

Mailing address

4701 Colony Dr
Jonesboro, AR 72404-9317
Phone (870) 932-4043

Other identifiers 1

IdentifierTypeStateIssuer
109054213MedicaidAR

Other names 1

  • Jonesboro Human Development Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1386770030. Details of each certification follow.

  • CCN 04G005 Intermediate care facility for individuals with intellectual disabilities · Active · Name & address match · Details

Intermediate care facility for individuals with intellectual disabilities certification: CCN 04G005

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
JONESBORO HUMAN DEVELOPMENT CENTER
Certification status
Active
Provider type (POS)
Intermediate care facility for individuals with intellectual disabilities
Participating since
Mar 1, 1983
Last certification
Jun 21, 2024
Beds
109
Ownership / control type
State
Facility address
4701 Colony Drive
Jonesboro, AR 72404

National Provider Directory

National Provider Directory
Tax ID family
State of Arkansas14 organizations share this tax ID, including this one

Other organizations with this tax ID 13

Organizations that report the same tax identification number in the National Provider Directory.

View all 13

Locations

4701 Colony Dr
Jonesboro, AR 72404
Phone (870) 932-4043

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1172448000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1692144000000",
    "number": "1386770030",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4701 COLONY DR",
            "city": "JONESBORO",
            "state": "AR",
            "postal_code": "724049317",
            "telephone_number": "870-932-4043",
            "fax_number": "870-932-4459"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4701 COLONY DR",
            "city": "JONESBORO",
            "state": "AR",
            "postal_code": "724049317",
            "telephone_number": "870-932-4043",
            "fax_number": "870-932-4459"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "STATE PF ARKANSAS",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-26",
        "last_updated": "2023-08-16",
        "status": "A",
        "authorized_official_last_name": "KEITH",
        "authorized_official_first_name": "THERESIA",
        "authorized_official_middle_name": "DIANE",
        "authorized_official_title_or_position": "SUPERINTENDENT",
        "authorized_official_telephone_number": "870-932-4043",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "320600000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "AR",
            "license": "137",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "109054213",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jonesboro Human Development Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Jonesboro Human Development Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jonesboro, AR

Sources for this page

Verify at the official NPI Registry.