Provider Demographics
NPI:1063464907
Name:HUCKABEE, JERRY LYNN (M ED LPC)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LYNN
Last Name:HUCKABEE
Suffix:
Gender:M
Credentials:M ED LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 BYRON ST
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-4602
Mailing Address - Country:US
Mailing Address - Phone:254-965-5327
Mailing Address - Fax:254-965-5327
Practice Address - Street 1:126 BYRON ST
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-4602
Practice Address - Country:US
Practice Address - Phone:254-965-5327
Practice Address - Fax:254-965-5327
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2009-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17322101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX011459448Medicaid