Provider Demographics
NPI:1689231904
Name:EDWARDS, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 HALBERT ST
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-2607
Mailing Address - Country:US
Mailing Address - Phone:501-332-4400
Mailing Address - Fax:501-332-4403
Practice Address - Street 1:829 HALBERT ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-2607
Practice Address - Country:US
Practice Address - Phone:501-332-4400
Practice Address - Fax:501-332-4403
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1908016101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health