Provider Demographics
NPI:1629214473
Name:WALSH, JERRY K (LPC, LADAC)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:K
Last Name:WALSH
Suffix:
Gender:M
Credentials:LPC, LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1832 PEARCE
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-2228
Mailing Address - Country:US
Mailing Address - Phone:870-904-2854
Mailing Address - Fax:870-234-3822
Practice Address - Street 1:229 A ST
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-3653
Practice Address - Country:US
Practice Address - Phone:870-234-6550
Practice Address - Fax:870-234-3822
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-29
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR0238L101YA0400X
ARP8101007101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)