=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881074755
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER NILES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2015
-----------------------------------------------------
Last Update Date | 06/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 S RAINBOW RD
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72758-8821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-254-1144
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 S BROADWAY ST B
-----------------------------------------------------
City | SILOAM SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72761-3130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-409-8102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | P1106033
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | M1106001
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------