Basic Information
| Provider Information | |||||||||
| NPI: | 1790064624 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MELDAHL | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | EDGAR | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1815 PLEASANT GROVE RD | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724017870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709336886 | ||||||||
| FaxNumber: | 8709339395 | ||||||||
| Practice Location | |||||||||
| Address1: | 2126 N 1ST STREET | ||||||||
| Address2: | SUITE F | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720762868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019825000 | ||||||||
| FaxNumber: | 5019825007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2011 | ||||||||
| LastUpdateDate: | 11/10/2016 | ||||||||
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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 | P9503006 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 187842795 | 05 | AR | MEDICAID | 5T153 | 01 | AR | BCBS | OTHER |