Provider Demographics
NPI:1710237581
Name:DAVIS, JACKALYN LEIGH (LPC)
Entity Type:Individual
Prefix:
First Name:JACKALYN
Middle Name:LEIGH
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:JACKALYN
Other - Middle Name:LEIGH
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:1815 PLEASANT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-7870
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:2126 N 1ST ST
Practice Address - Street 2:SUITE F
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-2868
Practice Address - Country:US
Practice Address - Phone:501-982-5000
Practice Address - Fax:501-982-5007
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1708271101Y00000X
171M00000X
ARP2203005101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR193514795Medicaid