Provider Demographics
NPI:1598038986
Name:WYATT, JALICIA (MHPP)
Entity Type:Individual
Prefix:
First Name:JALICIA
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 DOLLARWAY RD STE 105
Mailing Address - Street 2:
Mailing Address - City:WHITE HALL
Mailing Address - State:AR
Mailing Address - Zip Code:71602-3082
Mailing Address - Country:US
Mailing Address - Phone:870-247-2305
Mailing Address - Fax:870-247-2330
Practice Address - Street 1:7500 DOLLARWAY RD STE 105
Practice Address - Street 2:
Practice Address - City:WHITE HALL
Practice Address - State:AR
Practice Address - Zip Code:71602-3082
Practice Address - Country:US
Practice Address - Phone:870-247-2305
Practice Address - Fax:870-247-2330
Is Sole Proprietor?:No
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator