| Light Source Group Llc | |
|
625 N 1st St Ste 200 Jacksonville AR 72076-4117 | |
| (501) 985-0292 | |
| (501) 985-2070 |
| Full Name | Light Source Group Llc |
|---|---|
| Speciality | Clinic/center - Mental Health (including Community Mental Health Center) |
| Location | 625 N 1st St Ste 200, Jacksonville, Arkansas |
| Authorized Official Name and Position | Sean Michael Ronnau (COUNSELOR) |
| Authorized Official Contact | 5017470232 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Light Source Group Llc 625 N 1st St Ste 200 Jacksonville AR 72076-4117 Ph: (501) 985-0292 | Light Source Group Llc 625 N 1st St Ste 200 Jacksonville AR 72076-4117 Ph: (501) 985-0292 |
| NPI Number | 1922832906 |
|---|---|
| Provider Enumeration Date | 08/30/2024 |
| Last Update Date | 08/30/2024 |
| Certification Date | 08/30/2024 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1922832906 | NPI | - | NPPES |
| 1093960411 | Medicaid | AR |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
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