Organization
LIGHT SOURCE GROUP LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SEAN MICHAEL RONNAU LPC (COUNSELOR)
(501) 747-0232
Entity
Organization
Contact information
Practice address
625 N 1ST ST STE 200, JACKSONVILLE, AR 72076-4117
(501) 985-0292
(501) 985-2070
Mailing address
625 N 1ST ST STE 200, JACKSONVILLE, AR 72076-4117
(501) 985-0292
(501) 985-2070
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1093960411
—
AR
Enumeration date
08/30/2024
Last updated
11/18/2024
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