Provider Demographics
NPI:1073765657
Name:FETTING, ROSE JEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:JEAN
Last Name:FETTING
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JEANNIE
Other - Middle Name:
Other - Last Name:FETTING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:3 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 302 B
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-3728
Mailing Address - Country:US
Mailing Address - Phone:501-776-8447
Mailing Address - Fax:
Practice Address - Street 1:3 MEDICAL PARK DR
Practice Address - Street 2:SUITE 302 B
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3728
Practice Address - Country:US
Practice Address - Phone:501-776-8447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR104100000X
AR3915-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker