Individual
JACKSON LAKE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LAC
Contact information
Practice address
10020 N RODNEY PARHAM RD STE G, LITTLE ROCK, AR 72227-5588
(501) 831-4314
Mailing address
10020 N RODNEY PARHAM RD STE G, LITTLE ROCK, AR 72227-5588
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
A2305013
AR
Other
Enumeration date
06/19/2023
Last updated
06/19/2023
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