Provider Demographics
NPI:1194950774
Name:POLOVTSEV, JESSICA MARIE (LPC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:POLOVTSEV
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 SALEM RD STE 1
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-6166
Mailing Address - Country:US
Mailing Address - Phone:501-336-8300
Mailing Address - Fax:501-329-5508
Practice Address - Street 1:350 SALEM RD STE 1
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-6166
Practice Address - Country:US
Practice Address - Phone:501-336-8300
Practice Address - Fax:501-329-5508
Is Sole Proprietor?:No
Enumeration Date:2009-05-26
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1206061101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR179387795Medicaid