1093722571 NPI number — MRS. JACKIE DEE CUNNINGHAM LPC, LMFT

Table of content: MRS. JACKIE DEE CUNNINGHAM LPC, LMFT (NPI 1093722571)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093722571 NPI number — MRS. JACKIE DEE CUNNINGHAM LPC, LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUNNINGHAM
Provider First Name:
JACKIE
Provider Middle Name:
DEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC, LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093722571
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8208 TEAKWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WACO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76712-2426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-772-2780
Provider Business Mailing Address Fax Number:
254-741-1496

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6801 SANGER AVE
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
WACO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76710-7818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-741-1737
Provider Business Practice Location Address Fax Number:
254-741-1737
Provider Enumeration Date:
08/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  917 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 9087 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6159LC . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 156153201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 72716400 . This is a "MAGELLAN HEALTH" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 526067 . This is a "VALUE OPTIONS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 290089568 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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