Healthcare Provider Details

I. General information

NPI: 1700708138
Provider Name (Legal Business Name): JASON VALADEZ LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5004 W COLFAX LOOP
FAYETTEVILLE AR
72704-7724
US

IV. Provider business mailing address

5004 W COLFAX LOOP
FAYETTEVILLE AR
72704-7724
US

V. Phone/Fax

Practice location:
  • Phone: 502-262-5542
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA2407028
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: