Provider Demographics
NPI:1376000240
Name:JACQUEZ, EMILY J
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:J
Last Name:JACQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5121 CRESTWAY RD STE 200B
Mailing Address - Street 2:
Mailing Address - City:WINDCREST
Mailing Address - State:TX
Mailing Address - Zip Code:78239-1975
Mailing Address - Country:US
Mailing Address - Phone:800-805-6989
Mailing Address - Fax:
Practice Address - Street 1:5121 CRESTWAY RD STE 200B
Practice Address - Street 2:
Practice Address - City:WINDCREST
Practice Address - State:TX
Practice Address - Zip Code:78239-1975
Practice Address - Country:US
Practice Address - Phone:210-849-6188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41324101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)