Healthcare Provider Details

I. General information

NPI: 1609919612
Provider Name (Legal Business Name): JEROME GLYNN DIE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 12/07/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 SAINT VINCENT CIR SUITE 302
LITTLE ROCK AR
72205-5412
US

IV. Provider business mailing address

5 SAINT VINCENT CIR SUITE 302
LITTLE ROCK AR
72205-5412
US

V. Phone/Fax

Practice location:
  • Phone: 501-666-5242
  • Fax: 501-666-2430
Mailing address:
  • Phone: 501-666-5242
  • Fax: 501-666-2430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number92-25P
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number21056
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: