Provider Demographics
NPI:1215181565
Name:WASSON, JERILYN KAY (LPE)
Entity Type:Individual
Prefix:MS
First Name:JERILYN
Middle Name:KAY
Last Name:WASSON
Suffix:
Gender:F
Credentials:LPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 KIERRE LOOP
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-3726
Mailing Address - Country:US
Mailing Address - Phone:501-425-0472
Mailing Address - Fax:
Practice Address - Street 1:1221 KIERRE LOOP
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-3726
Practice Address - Country:US
Practice Address - Phone:501-425-0472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-13
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR08-04E101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health