Basic Information
| Provider Information | |||||||||
| NPI: | 1942849427 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACCHIAVERNA | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | LCSW, LCDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1430 COLLIER ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787042911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124724357 | ||||||||
| FaxNumber: | 5127031394 | ||||||||
| Practice Location | |||||||||
| Address1: | 8800 S 1ST ST APT 712 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787480008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5127852507 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2019 | ||||||||
| LastUpdateDate: | 06/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 12/31/2019 | ||||||||
| NPIReactivationDate: | 01/07/2020 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 14828 | TX | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 68837 | TX | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.