Provider Demographics
NPI:1932508041
Name:DAUGHERTY, JAMIE RENEE (LAC)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:RENEE
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 W FAULKNER ST
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-4519
Mailing Address - Country:US
Mailing Address - Phone:870-863-5153
Mailing Address - Fax:870-863-5154
Practice Address - Street 1:514 W FAULKNER ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4519
Practice Address - Country:US
Practice Address - Phone:870-863-5153
Practice Address - Fax:870-863-5154
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1407104101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health