MEDICARE: JAMIE RENEE DAUGHERTY LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	A1407104	AR

General Provider Information

NPI Number	:	1932508041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMIE RENEE DAUGHERTY LAC

Provider Business Mailing Address
First Line	:	514 W FAULKNER ST
Second Line	:
City	:	EL DORADO
State	:	AR
Zip	:	71730-4519
Country	:	US
Telephone Number	:	870-863-5153
Fax Number	:	870-863-5154

Provider Business Practice Location Address
First Line	:	514 W FAULKNER ST
Second Line	:
City	:	EL DORADO
State	:	AR
Zip	:	71730-4519
Country	:	US
Telephone Number	:	870-863-5153
Fax Number	:	870-863-5154

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2014
Last Update Date	:	08/14/2014

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