Provider Demographics
NPI:1164732566
Name:TOBAR-LAX, JACQUELINE ANNETTE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ANNETTE
Last Name:TOBAR-LAX
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 1:433 KITTY HAWK RD
Mailing Address - Street 2:
Mailing Address - City:UNIVERSAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78148-3357
Mailing Address - Country:US
Mailing Address - Phone:210-549-1704
Mailing Address - Fax:
Practice Address - Street 1:433 KITTY HAWK RD
Practice Address - Street 2:
Practice Address - City:UNIVERSAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78148-3357
Practice Address - Country:US
Practice Address - Phone:210-549-1704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA8063101Y00000X, 101YM0800X, 101YP2500X
TX74808101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
26-2586714OtherIRS EIN