Provider Demographics
NPI:1710136452
Name:CROMWELL, JUANNA JO (LAC)
Entity Type:Individual
Prefix:MS
First Name:JUANNA
Middle Name:JO
Last Name:CROMWELL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 DONS WAY
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-6478
Mailing Address - Country:US
Mailing Address - Phone:501-624-7111
Mailing Address - Fax:501-620-5109
Practice Address - Street 1:3399 FINCH RD
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:AR
Practice Address - Zip Code:71929-7541
Practice Address - Country:US
Practice Address - Phone:501-865-3363
Practice Address - Fax:501-865-3362
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA0707055101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116399726Medicaid