Healthcare Provider Details

I. General information

NPI: 1013461987
Provider Name (Legal Business Name): JEFFERSON COMPREHENSIVE COUNSELING ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2304 W 29TH AVE
PINE BLUFF AR
71603-5005
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: 870-671-4847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. SCOTT AARON MABRY
Title or Position: CLINICAL DIRECTOR
Credential: CADC, CCS
Phone: 870-247-5222