Provider Demographics
NPI:1134248164
Name:WHITE, VICKI (LCSW)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 W WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-2782
Mailing Address - Country:US
Mailing Address - Phone:870-972-4939
Mailing Address - Fax:870-972-4911
Practice Address - Street 1:533 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-2782
Practice Address - Country:US
Practice Address - Phone:870-229-0302
Practice Address - Fax:870-520-6482
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2623-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR227439719Medicaid