Provider Demographics
NPI:1467198358
Name:BURROUGHS, JAELEN
Entity Type:Individual
Prefix:
First Name:JAELEN
Middle Name:
Last Name:BURROUGHS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2695 DAVE WARD DR APT G6
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-6783
Mailing Address - Country:US
Mailing Address - Phone:205-603-0334
Mailing Address - Fax:
Practice Address - Street 1:2695 DAVE WARD DR APT G6
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-6783
Practice Address - Country:US
Practice Address - Phone:205-603-0334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician