Provider Demographics
NPI:1386850014
Name:PARKER, JACQUELINE S (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:S
Last Name:PARKER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:S
Other - Last Name:RILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4808 MILL CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-5018
Mailing Address - Country:US
Mailing Address - Phone:817-487-6775
Mailing Address - Fax:817-236-3827
Practice Address - Street 1:4524 BOAT CLUB RD
Practice Address - Street 2:SUITE 188
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-7025
Practice Address - Country:US
Practice Address - Phone:817-487-6775
Practice Address - Fax:817-236-3827
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX226631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149304101Medicaid
464056OtherVALUE OPTIONS
TX109828513OtherUBH