Basic Information
| Provider Information | |||||||||
| NPI: | 1225319379 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOUSWORTH | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW, LCDC | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | HOUSWORTH | ||||||||
| OtherFirstName: | JACK | ||||||||
| OtherMiddleName: | LEWIS | ||||||||
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| OtherCredential: | LMSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1430 COLLIER ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787042911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124724357 | ||||||||
| FaxNumber: | 5127031394 | ||||||||
| Practice Location | |||||||||
| Address1: | 403 E 15TH ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787011437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124724357 | ||||||||
| FaxNumber: | 5127031394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2011 | ||||||||
| LastUpdateDate: | 01/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 11262 | TX | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 60367 | TX | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.