Healthcare Provider Details

I. General information

NPI: 1467198358
Provider Name (Legal Business Name): JAELEN BURROUGHS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2608 S SHACKLEFORD RD STE C
LITTLE ROCK AR
72205-6932
US

IV. Provider business mailing address

2695 DAVE WARD DR APT G6
CONWAY AR
72034-6783
US

V. Phone/Fax

Practice location:
  • Phone: 501-999-3836
  • Fax:
Mailing address:
  • Phone: 205-603-0334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: