Healthcare Provider Details

I. General information

NPI: 1700228558
Provider Name (Legal Business Name): JEFFERSON COMPREHENSIVE COUNSELING ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2013
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 W 28TH AVE
PINE BLUFF AR
71603-4919
US

IV. Provider business mailing address

PO BOX 21203
WHITE HALL AR
71612-1203
US

V. Phone/Fax

Practice location:
  • Phone: 870-247-5222
  • Fax: 870-671-4847
Mailing address:
  • Phone: 870-247-5222
  • Fax: 870-247-4554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberP1211108
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: CHERISH E BILLINGSLEY
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 870-247-5222