Basic Information
| Provider Information | |||||||||
| NPI: | 1801001763 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAROTHERS | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4171 N CROSSOVER RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795211427 | ||||||||
| FaxNumber: | 4792498299 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 FORT ST STE A | ||||||||
| Address2: | |||||||||
| City: | BARLING | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729232180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794945700 | ||||||||
| FaxNumber: | 4794848142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.