Provider Demographics
NPI:1417691791
Name:ASHBROOK, DESTINY JADE (LCSW)
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:JADE
Last Name:ASHBROOK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5222 BELMONT AVE APT 110
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-6901
Mailing Address - Country:US
Mailing Address - Phone:913-526-1302
Mailing Address - Fax:
Practice Address - Street 1:17103 PRESTON RD STE 160
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-1486
Practice Address - Country:US
Practice Address - Phone:913-526-1302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-23
Last Update Date:2022-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX627231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty