Provider Demographics
NPI:1114125127
Name:DAVIS, BILL JACK (MA)
Entity Type:Individual
Prefix:MR
First Name:BILL
Middle Name:JACK
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77301-2568
Mailing Address - Country:US
Mailing Address - Phone:936-441-8255
Mailing Address - Fax:936-756-8348
Practice Address - Street 1:420 W LEWIS ST
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301-2568
Practice Address - Country:US
Practice Address - Phone:936-441-8255
Practice Address - Fax:936-756-8348
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11269101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional