Healthcare Provider Details

I. General information

NPI: 1205294675
Provider Name (Legal Business Name): JENNIFER DAVIS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2016
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7701 S ZERO ST
FORT SMITH AR
72903-6644
US

IV. Provider business mailing address

PO BOX 11495
FORT SMITH AR
72917-1495
US

V. Phone/Fax

Practice location:
  • Phone: 479-478-5622
  • Fax: 501-222-6117
Mailing address:
  • Phone: 479-478-5622
  • Fax: 501-222-6117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP1810144
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: