Healthcare Provider Details

I. General information

NPI: 1801131560
Provider Name (Legal Business Name): JACQUELINE HENDERSON CIT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3204 E MOORE AVE
SEARCY AR
72143-4826
US

IV. Provider business mailing address

3204 E MOORE AVE
SEARCY AR
72143-4826
US

V. Phone/Fax

Practice location:
  • Phone: 501-268-7777
  • Fax: 501-305-5009
Mailing address:
  • Phone: 501-268-7777
  • Fax: 501-305-5009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: