Basic Information
| Provider Information | |||||||||
| NPI: | 1568734036 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HURTADO | ||||||||
| FirstName: | JACKELINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M.ED., LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 66308 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772666308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8325485000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6550 MAPLERIDGE ST | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770814600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133517360 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2012 | ||||||||
| LastUpdateDate: | 09/14/2015 | ||||||||
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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 | 65735 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 741819 | 01 | TX | LEGACY SITE SPECIFIC MEDICARE # | OTHER | 080462703 | 01 | TX | LEGACY COMMUNITY HEALTH SERVICES, INC MEDICAID # | OTHER |