Provider Demographics
NPI:1407180557
Name:KILLION, JENNIE LYNN (MS, LAC)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:LYNN
Last Name:KILLION
Suffix:
Gender:F
Credentials:MS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4111 W MOSSY ROCK DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-6392
Mailing Address - Country:US
Mailing Address - Phone:479-442-7480
Mailing Address - Fax:
Practice Address - Street 1:2301 W WALNUT ST
Practice Address - Street 2:SUITE 7
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-3586
Practice Address - Country:US
Practice Address - Phone:479-936-5944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-22
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA0907076101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional