Basic Information
| Provider Information | |||||||||
| NPI: | 1871748756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVENNY | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD, LP | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2005 W ELM ST | ||||||||
| Address2: | |||||||||
| City: | ROGERS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727584018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796360083 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2005 W ELM ST | ||||||||
| Address2: | |||||||||
| City: | ROGERS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727584018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796360083 | ||||||||
| FaxNumber: | 4796360144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2008 | ||||||||
| LastUpdateDate: | 07/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 20-04P | AR | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 32977400 | 05 | WI | MEDICAID | 237737795 | 05 | AR | MEDICAID | 490082121 | 05 | MO | MEDICAID |