Healthcare Provider Details

I. General information

NPI: 1760659031
Provider Name (Legal Business Name): JEREMY TRULL LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 MCAFEE MEDICAL CIRCLE
BEEBE AR
72012-2217
US

IV. Provider business mailing address

905 MCAFEE MEDICAL CIRCLE
BEEBE AR
72012-2217
US

V. Phone/Fax

Practice location:
  • Phone: 501-232-2600
  • Fax: 501-242-0820
Mailing address:
  • Phone: 501-232-2600
  • Fax: 501-242-0820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP1711379
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: