=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821680505
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY MARTIN ERICKSON JR. LAC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2021
-----------------------------------------------------
Last Update Date | 02/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4702 W COMMERCIAL DR STE B3
-----------------------------------------------------
City | NORTH LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72116-7073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-205-4570
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29 ODOM RD
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72032-9031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-286-2441
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | A2009118
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------