Provider Demographics
NPI:1164577078
Name:KORSON, MARY JANE (LICENSED PROFESSIONA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JANE
Last Name:KORSON
Suffix:
Gender:F
Credentials:LICENSED PROFESSIONA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3978 COUNTY ROAD 37
Mailing Address - Street 2:
Mailing Address - City:CLARKRIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72623
Mailing Address - Country:US
Mailing Address - Phone:870-425-3681
Mailing Address - Fax:
Practice Address - Street 1:312 BOMBER BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653
Practice Address - Country:US
Practice Address - Phone:870-425-3840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP0608047101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional