Provider Information for 1659048809
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JEANIE RAY SHADE LCSW
Sex: Female
NPI: 1659048809
Last Updated: 2023-12-06
Certification Date: 2023-12-06
Certification Date: 2023-12-06
Details
| Name | Value | ||||||||
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| NPI | 1659048809 | ||||||||
| Enumeration Date | 2021-08-25 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | YES | ||||||||
| Status | Active | ||||||||
| Mailing Address | 53 NANTUCKET DR BELLA VISTA, AR 72715-8178 United States Phone: 208-749-4323 | Fax: | ||||||||
| Primary Practice Address | 1001 SE 28TH ST BENTONVILLE, AR 72712-3205 United States Phone: 479-403-2915 | Fax: | ||||||||
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