Healthcare Provider Details

I. General information

NPI: 1881426500
Provider Name (Legal Business Name): JERRY MCDONIEL LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 MORGAN STREET SUITE 8
PARAGOULD AR
72450-3949
US

IV. Provider business mailing address

1815 PLEASANT GROVE RD
JONESBORO AR
72405-7870
US

V. Phone/Fax

Practice location:
  • Phone: 870-335-9483
  • Fax: 870-335-9487
Mailing address:
  • Phone: 870-933-6886
  • Fax: 870-933-9395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA2408007
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: