Provider Demographics
NPI:1922365691
Name:TAYLOR, JEREMIAH (LMFT)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 OAK ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-4408
Mailing Address - Country:US
Mailing Address - Phone:501-279-9000
Mailing Address - Fax:501-279-9011
Practice Address - Street 1:812 OAK ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-4408
Practice Address - Country:US
Practice Address - Phone:501-327-7100
Practice Address - Fax:501-327-7121
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR0261L101YA0400X
ARM0708004106H00000X
ARP1810139101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR0261LOtherLICENSED ALCOHOLISM AND DRUG ABUSE COUNSELOR
ARM0708004OtherLMFT