Basic Information
| Provider Information | |||||||||
| NPI: | 1114338811 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRUSSELL | ||||||||
| FirstName: | JARED | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 W GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719013931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017670051 | ||||||||
| FaxNumber: | 5017670059 | ||||||||
| Practice Location | |||||||||
| Address1: | 1405 N PIERCE ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016032147 | ||||||||
| FaxNumber: | 5016030324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2014 | ||||||||
| LastUpdateDate: | 08/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | P1704288 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | A1404070 | AR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.