Basic Information
Provider Information | |||||||||
NPI: | 1861050858 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOLLINGSWORTH | ||||||||
FirstName: | HEATHER | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GOULD | ||||||||
OtherFirstName: | HEATHER | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LAC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1815 PLEASANT GROVE ROAD | ||||||||
Address2: |   | ||||||||
City: | JONESBORO | ||||||||
State: | AR | ||||||||
PostalCode: | 724057870 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8709336886 | ||||||||
FaxNumber: | 8709339395 | ||||||||
Practice Location | |||||||||
Address1: | 2126 N 1ST ST | ||||||||
Address2: | SUITE F | ||||||||
City: | JACKSONVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 720762868 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5019825000 | ||||||||
FaxNumber: | 5019825007 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/04/2019 | ||||||||
LastUpdateDate: | 12/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | P2110016 | AR | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 233999795 | 05 | AR |   | MEDICAID |