Basic Information
Provider Information | |||||||||
NPI: | 1629548458 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLLINS | ||||||||
FirstName: | JENNA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CAHOON | ||||||||
OtherFirstName: | JENNA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LCSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 497 | ||||||||
Address2: |   | ||||||||
City: | AUGUSTA | ||||||||
State: | AR | ||||||||
PostalCode: | 720060497 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8703472534 | ||||||||
FaxNumber: | 8703471235 | ||||||||
Practice Location | |||||||||
Address1: | 2805 MID CITIES DR STE 1 | ||||||||
Address2: |   | ||||||||
City: | BENTONVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 727124291 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4792717634 | ||||||||
FaxNumber: | 7492717654 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/05/2018 | ||||||||
LastUpdateDate: | 09/12/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/12/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 8916-M | AR | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 171M00000X | 8916-M | AR | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 104100000X | 8916-C | AR | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
ID Information
ID | Type | State | Issuer | Description | 248897719 | 05 | AR |   | MEDICAID |