Provider Demographics
NPI:1225319379
Name:HOUSWORTH, JACK (LCSW, LCDC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:HOUSWORTH
Suffix:
Gender:M
Credentials:LCSW, LCDC
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:LEWIS
Other - Last Name:HOUSWORTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:1430 COLLIER ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-2911
Mailing Address - Country:US
Mailing Address - Phone:512-472-4357
Mailing Address - Fax:512-703-1394
Practice Address - Street 1:403 E 15TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-1437
Practice Address - Country:US
Practice Address - Phone:512-472-4357
Practice Address - Fax:512-703-1394
Is Sole Proprietor?:No
Enumeration Date:2011-09-02
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11262101YA0400X
TX603671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)