=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528238862
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER LEIGH HOLLIS LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2008
-----------------------------------------------------
Last Update Date | 08/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 LINDAUER RD
-----------------------------------------------------
City | FORREST CITY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72335-2404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-494-4600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 11064
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72703-1001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-520-5014
-----------------------------------------------------
Fax | 870-520-5015
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2217-C
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------