Provider Demographics
NPI:1093722571
Name:CUNNINGHAM, JACKIE DEE (LPC, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:DEE
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8208 TEAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-2426
Mailing Address - Country:US
Mailing Address - Phone:254-772-2780
Mailing Address - Fax:254-741-1496
Practice Address - Street 1:6801 SANGER AVE
Practice Address - Street 2:STE 201
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-7818
Practice Address - Country:US
Practice Address - Phone:254-741-1737
Practice Address - Fax:254-741-1737
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX917106H00000X
TX9087101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6159LCOtherBLUE CROSS BLUE SHIELD
TX156153201Medicaid
TX72716400OtherMAGELLAN HEALTH
TX526067OtherVALUE OPTIONS
TX290089568OtherUNITED BEHAVIORAL HEALTH