Provider Demographics
NPI:1891506531
Name:ROLLINS, JACK TYLER (MS, LAC)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:TYLER
Last Name:ROLLINS
Suffix:
Gender:M
Credentials:MS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3230 MARKET PLACE AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-8074
Mailing Address - Country:US
Mailing Address - Phone:501-781-2230
Mailing Address - Fax:
Practice Address - Street 1:3230 MARKET PLACE AVE STE 4
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-8074
Practice Address - Country:US
Practice Address - Phone:501-781-2230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health