| Doctor Name: | MR. JEREMY RUSSELL ANDERSON |
| NPI Number: | 1003946369 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LPC |
| License Number: | P1307080 |
| Business Practice Address: | 1815 Pleasant Grove Road Jonesboro, AR - 724017870 |
| Business Phone Number: | 8709336886 |
| Business Fax Number: | 8709339395 |
| Mailing Address: | 1815 Pleasant Grove Road, JONESBORO |
| State: | AR |
| Postal Code: | 724017870 |
| Phone Number: | 8709336886 |
| Fax Number: | 8709339395 |
| NPI Enumeration Date: | 03/06/2007 |
| NPI Last Update Date: | 02/12/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | P1307080 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | AR |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |