1386019123 NPI number — MRS. JACQUELINE MARIE BROCK LPC

Table of content: MRS. JACQUELINE MARIE BROCK LPC (NPI 1386019123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386019123 NPI number — MRS. JACQUELINE MARIE BROCK LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROCK
Provider First Name:
JACQUELINE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HARRIS
Provider Other First Name:
JACQUELINE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC, ATR
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1386019123
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14 BENDING BR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76513-7507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-833-0781
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14 BENDING BR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76513-7507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-833-0781
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/04/2015

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: 174400000X , with the licence number:  70143 , 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: 70143 , 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)





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