Healthcare Provider Details

I. General information

NPI: 1588294631
Provider Name (Legal Business Name): PUZZLE COLLABORATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2020
Last Update Date: 01/16/2020
Certification Date: 01/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 W COLT SQUARE DR STE 1
FAYETTEVILLE AR
72703-2888
US

IV. Provider business mailing address

1189 LEELYNJEAN LN
SPRINGDALE AR
72762-0801
US

V. Phone/Fax

Practice location:
  • Phone: 479-200-0965
  • Fax: 479-935-9187
Mailing address:
  • Phone: 479-200-0965
  • Fax: 918-747-9935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JESSICA C KITCHENS
Title or Position: OWNER
Credential: LPC, LADAC, MAC, CAS
Phone: 479-200-0965