Provider Demographics
NPI:1689300923
Name:ICE, JASMINE CHEYENNE
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:CHEYENNE
Last Name:ICE
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 1:6212 MILSAP DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDER
Mailing Address - State:AR
Mailing Address - Zip Code:72002-7039
Mailing Address - Country:US
Mailing Address - Phone:870-730-8837
Mailing Address - Fax:
Practice Address - Street 1:3401 HWY 5 N STE 2
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72019-9103
Practice Address - Country:US
Practice Address - Phone:501-777-5969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2204018101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health