Healthcare Provider Details

I. General information

NPI: 1013380930
Provider Name (Legal Business Name): TAMMY JERRY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2015
Last Update Date: 05/05/2022
Certification Date: 05/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N MAIN ST
JUNCTION CITY AR
71749-9597
US

IV. Provider business mailing address

1070 W STATELINE RD
JUNCTION CITY AR
71749-9430
US

V. Phone/Fax

Practice location:
  • Phone: 870-314-9921
  • Fax: 870-621-0088
Mailing address:
  • Phone: 870-314-9921
  • Fax: 870-621-0088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5405
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP2103163
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: