Provider Demographics
NPI:1093207615
Name:ANDERSON, JARROD (MS, LPC, LMFT)
Entity Type:Individual
Prefix:
First Name:JARROD
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MS, LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12694 MILLER CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-9041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2105 S 54TH ST STE 2
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8191
Practice Address - Country:US
Practice Address - Phone:479-268-4557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1805010106H00000X
ARP1805062101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist