Healthcare Provider Details

I. General information

NPI: 1023255106
Provider Name (Legal Business Name): COUNSELING ASSOCIATES OF THE FOUR STATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2009
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 W 26TH ST
JOPLIN MO
64804-1904
US

IV. Provider business mailing address

705 W 26TH ST
JOPLIN MO
64804-1904
US

V. Phone/Fax

Practice location:
  • Phone: 417-627-9994
  • Fax: 417-627-9995
Mailing address:
  • Phone: 417-627-9994
  • Fax: 417-627-9995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JACOB RUSSELL CONKLIN
Title or Position: OWNER, LPC
Credential: LPC
Phone: 417-627-9994