Healthcare Provider Details

I. General information

NPI: 1881074755
Provider Name (Legal Business Name): JENNIFER NILES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2015
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 S RAINBOW RD
ROGERS AR
72758-8821
US

IV. Provider business mailing address

200 S BROADWAY ST B
SILOAM SPRINGS AR
72761-3130
US

V. Phone/Fax

Practice location:
  • Phone: 479-254-1144
  • Fax:
Mailing address:
  • Phone: 479-409-8102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP1106033
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberM1106001
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: