Healthcare Provider Details

I. General information

NPI: 1912813874
Provider Name (Legal Business Name): MIRACLE KIDS SUCCESS ACADEMY NORTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 GLENDALE ST
JONESBORO AR
72401-4455
US

IV. Provider business mailing address

806 GLENDALE ST
JONESBORO AR
72401-4455
US

V. Phone/Fax

Practice location:
  • Phone: 870-333-2600
  • Fax: 870-300-2337
Mailing address:
  • Phone: 870-333-2600
  • Fax: 870-300-2337

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: SHELLY A. KELLER
Title or Position: CEO
Credential:
Phone: 870-932-3600