Healthcare Provider Details

I. General information

NPI: 1346168333
Provider Name (Legal Business Name): MIRACLE KIDS SUCCESS ACADEMY CENTRAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

1607 STONE ST
JONESBORO AR
72401-5332
US

IV. Provider business mailing address

1607 STONE ST
JONESBORO AR
72401-5332
US

V. Phone/Fax

Practice location:
  • Phone: 870-336-4100
  • Fax:
Mailing address:
  • Phone: 870-336-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: JEREMY EDWARD ELLIS
Title or Position: CONTROLLER
Credential:
Phone: 870-336-4100