Provider Demographics
NPI:1912342692
Name:JEFFERSON COMPREHENSIVE COUNSELING ASSOCIATES, INC.
Entity Type:Organization
Organization Name:JEFFERSON COMPREHENSIVE COUNSELING ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:MABRY
Authorized Official - Suffix:
Authorized Official - Credentials:CADC, CCS
Authorized Official - Phone:870-247-5222
Mailing Address - Street 1:PO BOX 21203
Mailing Address - Street 2:
Mailing Address - City:WHITE HALL
Mailing Address - State:AR
Mailing Address - Zip Code:71612-1203
Mailing Address - Country:US
Mailing Address - Phone:870-247-5222
Mailing Address - Fax:870-247-4554
Practice Address - Street 1:5103 W MALCOMB ST
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71602-4649
Practice Address - Country:US
Practice Address - Phone:870-247-5222
Practice Address - Fax:870-247-4554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-07
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1211108261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health