Provider Demographics
NPI:1235704990
Name:JACKLIN, REBECCA CANDLAND (LMSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:CANDLAND
Last Name:JACKLIN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16019 DIANA LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77062-4406
Mailing Address - Country:US
Mailing Address - Phone:832-549-9444
Mailing Address - Fax:
Practice Address - Street 1:633 E FERNHURST DR STE 304
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-1586
Practice Address - Country:US
Practice Address - Phone:817-753-0022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX689781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX68978OtherSTATE LICENSE