Healthcare Provider Details

I. General information

NPI: 1053833061
Provider Name (Legal Business Name): KATIE JEAN WELLS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2017
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 DAVID ST
CORNING AR
72422-7268
US

IV. Provider business mailing address

2707 BROWNS LN
JONESBORO AR
72401-7213
US

V. Phone/Fax

Practice location:
  • Phone: 870-857-3655
  • Fax: 870-857-3667
Mailing address:
  • Phone: 870-972-4939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8394C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: