Basic Information
Provider Information | |||||||||
NPI: | 1720395494 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JESSICA CALLICUTT COUNSELING LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1755 N COLLINS BLVD | ||||||||
Address2: | SUITE 525 | ||||||||
City: | RICHARDSON | ||||||||
State: | TX | ||||||||
PostalCode: | 750803613 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2143695522 | ||||||||
FaxNumber: | 2143695327 | ||||||||
Practice Location | |||||||||
Address1: | 1755 N COLLINS BLVD | ||||||||
Address2: | SUITE 525 | ||||||||
City: | RICHARDSON | ||||||||
State: | TX | ||||||||
PostalCode: | 750803613 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2143695522 | ||||||||
FaxNumber: | 2143695327 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/01/2010 | ||||||||
LastUpdateDate: | 10/07/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CALLICUTT | ||||||||
AuthorizedOfficialFirstName: | JESSICA | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/LICENSED COUNSELOR | ||||||||
AuthorizedOfficialTelephone: | 2147286861 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MS, LPC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 64222 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.