Basic Information
| Provider Information | |||||||||
| NPI: | 1902126683 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAQUITH | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JAQUITH | ||||||||
| OtherFirstName: | JERI | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7807 WILLIAMSON CREEK DR | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787362976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129400191 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 56 EAST AVE | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787014323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5127031312 | ||||||||
| FaxNumber: | 5127031390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2010 | ||||||||
| LastUpdateDate: | 06/11/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 18022 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 211799604 | 05 | TX | MEDICAID |