Provider Demographics
NPI:1821680505
Name:ERICKSON, JERRY MARTIN JR (LAC)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:MARTIN
Last Name:ERICKSON
Suffix:JR
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 ODOM RD
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-9031
Mailing Address - Country:US
Mailing Address - Phone:910-286-2441
Mailing Address - Fax:
Practice Address - Street 1:4702 W COMMERCIAL DR STE B3
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-7073
Practice Address - Country:US
Practice Address - Phone:501-205-4570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2009118101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health