Provider Demographics
NPI:1043600596
Name:DALLAS NEW LEAF CLINIC
Entity Type:Organization
Organization Name:DALLAS NEW LEAF CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSESSMENT COUNSELOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:469-251-0803
Mailing Address - Street 1:17103 PRESTON RD
Mailing Address - Street 2:SUITE 288
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-1332
Mailing Address - Country:US
Mailing Address - Phone:469-251-0803
Mailing Address - Fax:
Practice Address - Street 1:17103 PRESTON RD
Practice Address - Street 2:SUITE 288
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-1332
Practice Address - Country:US
Practice Address - Phone:469-251-0803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20192101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty