Provider Demographics
NPI:1134341076
Name:HENRY, KEISHA DENYTHIA (PHD)
Entity type:Individual
Prefix:DR
First Name:KEISHA
Middle Name:DENYTHIA
Last Name:HENRY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1126
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72078
Mailing Address - Country:US
Mailing Address - Phone:501-987-7338
Mailing Address - Fax:501-987-8087
Practice Address - Street 1:314 MEDICAL GROUP, LIFE SKILLS SUPPORT CENTER
Practice Address - Street 2:1090 ARNOLD DRIVE
Practice Address - City:LITTLE ROCK AFB
Practice Address - State:AR
Practice Address - Zip Code:72099
Practice Address - Country:US
Practice Address - Phone:501-987-7338
Practice Address - Fax:501-987-8087
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1433103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical