1700228558 NPI number — JEFFERSON COMPREHENSIVE COUNSELING ASSOCIATES

Table of content: (NPI 1700228558)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700228558 NPI number — JEFFERSON COMPREHENSIVE COUNSELING ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFERSON COMPREHENSIVE COUNSELING ASSOCIATES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700228558
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 21203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE HALL
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71612-1203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-247-5222
Provider Business Mailing Address Fax Number:
870-247-4554

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2720 W 28TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINE BLUFF
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71603-4919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-247-5222
Provider Business Practice Location Address Fax Number:
870-671-4847
Provider Enumeration Date:
07/22/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BILLINGSLEY
Authorized Official First Name:
CHERISH
Authorized Official Middle Name:
E
Authorized Official Title or Position:
ADMINISTRATIVE DIRECTOR
Authorized Official Telephone Number:
870-247-5222

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM0855X , with the licence number: P1211108 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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