Provider Demographics
NPI:1457838187
Name:WADDELL, JONATHAN EDWIN (LCSW)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:EDWIN
Last Name:WADDELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 251418
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72225-1418
Mailing Address - Country:US
Mailing Address - Phone:501-364-1100
Mailing Address - Fax:501-364-4082
Practice Address - Street 1:1210 WOLFE ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-4618
Practice Address - Country:US
Practice Address - Phone:501-364-5150
Practice Address - Fax:501-364-3966
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR8906-M104100000X
AR8906-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR221648795Medicaid