Provider Demographics
NPI:1437692720
Name:PETTYJOHN, GINAH BRIANNE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:GINAH
Middle Name:BRIANNE
Last Name:PETTYJOHN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 E CENTERTON BLVD APT 1312
Mailing Address - Street 2:
Mailing Address - City:CENTERTON
Mailing Address - State:AR
Mailing Address - Zip Code:72719-7917
Mailing Address - Country:US
Mailing Address - Phone:479-257-5070
Mailing Address - Fax:
Practice Address - Street 1:685 SHELBY TRL STE 105
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-7169
Practice Address - Country:US
Practice Address - Phone:501-406-0504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-18
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1811147101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional