Provider Demographics
NPI:1417208612
Name:MACK, JENNA A (MED, LPC)
Entity Type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:A
Last Name:MACK
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 S WHITE CHAPEL BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-9315
Mailing Address - Country:US
Mailing Address - Phone:214-810-3756
Mailing Address - Fax:
Practice Address - Street 1:1207 S WHITE CHAPEL BLVD STE 105
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-9315
Practice Address - Country:US
Practice Address - Phone:214-810-3756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-27
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66288101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health