MEDICARE: MS. JERILYN KAY WASSON LPE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	08-04E	AR

General Provider Information

NPI Number	:	1215181565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JERILYN KAY WASSON LPE

Provider Business Mailing Address
First Line	:	1221 KIERRE LOOP
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72116-3726
Country	:	US
Telephone Number	:	501-425-0472
Fax Number	:

Provider Business Practice Location Address
First Line	:	1221 KIERRE LOOP
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72116-3726
Country	:	US
Telephone Number	:	501-425-0472
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2008
Last Update Date	:	05/27/2010

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