Provider Demographics
NPI:1871849422
Name:EDWARDS, JAMES RAYNARD (MED)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:RAYNARD
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:1815 PLEASANT GROVE ROAD
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 1:3201 W. KEISER
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:AR
Practice Address - Zip Code:72370-3467
Practice Address - Country:US
Practice Address - Phone:870-622-0592
Practice Address - Fax:870-622-0782
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP2002014101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR238797719Medicaid