Basic Information
| Provider Information | |||||||||
| NPI: | 1447376546 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GENTRY | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 110 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728013362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799675570 | ||||||||
| FaxNumber: | 4798905364 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728013362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799681298 | ||||||||
| FaxNumber: | 4799686053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | P0611062 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 226868719 | 05 | AR | MEDICAID |