Provider Demographics
NPI:1437301835
Name:BEASLEY, JEREMEY (LPC)
Entity Type:Individual
Prefix:
First Name:JEREMEY
Middle Name:
Last Name:BEASLEY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 LINWOOD DR STE G
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-5365
Mailing Address - Country:US
Mailing Address - Phone:870-604-4455
Mailing Address - Fax:888-977-2956
Practice Address - Street 1:1707 LINWOOD DR STE G
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-5365
Practice Address - Country:US
Practice Address - Phone:870-604-4455
Practice Address - Fax:888-977-2956
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-16
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ARP1707328101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116399726Medicaid