Healthcare Provider Details

I. General information

NPI: 1063209823
Provider Name (Legal Business Name): BLOSSOM ON PURPOSE THERAPY & CONSULTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2025
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 MUNICIPAL DRIVE
JACKSONVILLE AR
72076-4274
US

IV. Provider business mailing address

140 MUNICIPAL DR
JACKSONVILLE AR
72076-4274
US

V. Phone/Fax

Practice location:
  • Phone: 501-243-8977
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VICKY BAKER
Title or Position: OWNER/THERAPIST
Credential: LCSW
Phone: 501-243-8977