Basic Information
| Provider Information | |||||||||
| NPI: | 1043409634 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BELDEN | ||||||||
| FirstName: | JACKLYN | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | L.P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3131 SANGUINET ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761075336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172355747 | ||||||||
| FaxNumber: | 8175694517 | ||||||||
| Practice Location | |||||||||
| Address1: | 3131 SANGUINET ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761075336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172355747 | ||||||||
| FaxNumber: | 8175694517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2007 | ||||||||
| LastUpdateDate: | 03/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 17992 | TX | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 17992 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 192113201 | 05 | TX | MEDICAID | 192113202 | 05 | TX | MEDICAID |