Provider Demographics
NPI:1043409634
Name:BELDEN, JACKLYN F (LPC)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:F
Last Name:BELDEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 SANGUINET ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-5336
Mailing Address - Country:US
Mailing Address - Phone:817-235-5747
Mailing Address - Fax:817-569-4517
Practice Address - Street 1:3131 SANGUINET ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-5336
Practice Address - Country:US
Practice Address - Phone:817-235-5747
Practice Address - Fax:817-569-4517
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17992101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX192113201Medicaid
TX192113202Medicaid