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General NPI Number Information
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NPI Number | 1144651050
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Entity Type | Organization
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Legal Business Name | LIGHTHOUSE PROFESSIONAL CLINICS INC
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Dates
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Enumeration Date | 12/02/2013
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Last Update Date | 05/02/2014
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Provider Practice Location Address
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Address Line | 2024 ARKANSAS VALLEY DR STE 206
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City | LITTLE ROCK
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State | AR
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Zip | 72212-4166
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Country | US
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Telephone | 501-246-7171
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Fax | 501-246-7171
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Provider Business Mailing Address
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Address Line | 2024 ARKANSAS VALLEY DR STE 206
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City | LITTLE ROCK
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State | AR
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Zip | 72212-4166
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Country | US
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Telephone | 501-246-7171
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Fax | 501-246-7171
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MELISSA FAYE JACKSON
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Credential | PHD
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Telephone | 205-565-1694
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 12-19P
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License Number State | AR
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