Basic Information
| Provider Information | |||||||||
| NPI: | 1770667859 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAMESON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 128 SOUTHWINDS RD STE 5 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727308685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792676934 | ||||||||
| FaxNumber: | 8667893345 | ||||||||
| Practice Location | |||||||||
| Address1: | 128 SOUTHWINDS RD STE 5 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727308685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792676934 | ||||||||
| FaxNumber: | 8667893345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 04/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | 95-22P | AR | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling |
ID Information
| ID | Type | State | Issuer | Description | 128264719 | 05 | AR | MEDICAID |