Provider Demographics
NPI:1205820545
Name:ROSENBERGER, JACKIE (LICSW)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:ROSENBERGER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1181 SHARPSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-6330
Mailing Address - Country:US
Mailing Address - Phone:214-399-3918
Mailing Address - Fax:
Practice Address - Street 1:1181 SHARPSHIRE CT
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-6330
Practice Address - Country:US
Practice Address - Phone:214-399-3918
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-01
Last Update Date:2007-07-08
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-05-22
Provider Licenses
StateLicense IDTaxonomies
TX40193101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP05198Medicare ID - Type UnspecifiedMEDICARE ID