Provider Demographics
NPI:1700228558
Name:JEFFERSON COMPREHENSIVE COUNSELING ASSOCIATES
Entity Type:Organization
Organization Name:JEFFERSON COMPREHENSIVE COUNSELING ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERISH
Authorized Official - Middle Name:E
Authorized Official - Last Name:BILLINGSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-247-5222
Mailing Address - Street 1:PO BOX 21203
Mailing Address - Street 2:
Mailing Address - City:WHITE HALL
Mailing Address - State:AR
Mailing Address - Zip Code:71612-1203
Mailing Address - Country:US
Mailing Address - Phone:870-247-5222
Mailing Address - Fax:870-247-4554
Practice Address - Street 1:2720 W 28TH AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-4919
Practice Address - Country:US
Practice Address - Phone:870-247-5222
Practice Address - Fax:870-671-4847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-22
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ARP1211108261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty