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General NPI Number Information
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NPI Number | 1164577078
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Entity Type | Individual
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Provider Name | MARY JANE KORSON LICENSED PROFESSIONA
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Gender | Female
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Dates
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Enumeration Date | 01/24/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 312 BOMBER BLVD
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City | MOUNTAIN HOME
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State | AR
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Zip | 72653
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Country | US
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Telephone | 870-425-3840
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Fax |
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Provider Business Mailing Address
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Address Line | 3978 COUNTY ROAD 37
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City | CLARKRIDGE
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State | AR
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Zip | 72623
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Country | US
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Telephone | 870-425-3681
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | P0608047
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License Number State | AR
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