Healthcare Provider Details

I. General information

NPI: 1194950774
Provider Name (Legal Business Name): JESSICA MARIE POLOVTSEV LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 SALEM RD STE 1
CONWAY AR
72034-6166
US

IV. Provider business mailing address

350 SALEM RD STE 1
CONWAY AR
72034-6166
US

V. Phone/Fax

Practice location:
  • Phone: 501-336-8300
  • Fax: 501-329-5508
Mailing address:
  • Phone: 501-336-8300
  • Fax: 501-329-5508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP1206061
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP1206061
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: