Provider Demographics
NPI:1659048809
Name:SHADE, JEANIE RAY (LCSW)
Entity type:Individual
Prefix:
First Name:JEANIE
Middle Name:RAY
Last Name:SHADE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 NANTUCKET DR
Mailing Address - Street 2:
Mailing Address - City:BELLA VISTA
Mailing Address - State:AR
Mailing Address - Zip Code:72715-8178
Mailing Address - Country:US
Mailing Address - Phone:208-749-4323
Mailing Address - Fax:
Practice Address - Street 1:1001 SE 28TH ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3205
Practice Address - Country:US
Practice Address - Phone:479-403-2915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-25
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR12579-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical