Basic Information
| Provider Information | |||||||||
| NPI: | 1558302927 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARADISE | ||||||||
| FirstName: | JEANIE | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1703 N LOOP 1604 # 16107 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102593628 | ||||||||
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| Practice Location | |||||||||
| Address1: | 527 N LEONA ST | ||||||||
| Address2: | CRISIS CARE CENTER | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782073110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107311300 | ||||||||
| FaxNumber: | 2103586918 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 09/24/2010 | ||||||||
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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 | 101YP2500X | 17533 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 148852001 | 05 | TX | MEDICAID |