Provider Demographics
NPI:1386019123
Name:BROCK, JACQUELINE MARIE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MARIE
Last Name:BROCK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MISS
Other - First Name:JACQUELINE
Other - Middle Name:MARIE
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC, ATR
Mailing Address - Street 1:14 BENDING BR
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:TX
Mailing Address - Zip Code:76513-7507
Mailing Address - Country:US
Mailing Address - Phone:254-833-0781
Mailing Address - Fax:
Practice Address - Street 1:14 BENDING BR
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:TX
Practice Address - Zip Code:76513-7507
Practice Address - Country:US
Practice Address - Phone:254-833-0781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-04
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70143174400000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No174400000XOther Service ProvidersSpecialist