Healthcare Provider Details

I. General information

NPI: 1548386477
Provider Name (Legal Business Name): ALLISON JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 MANOR ST
MARION AR
72364-1936
US

IV. Provider business mailing address

109 ELDRIDGE CT
WYNNE AR
72396-2306
US

V. Phone/Fax

Practice location:
  • Phone: 870-739-6818
  • Fax:
Mailing address:
  • Phone: 870-238-8026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: