Provider Demographics
NPI:1427576693
Name:RUDD, JEREMY DANIEL (MA, LPC, CCM)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DANIEL
Last Name:RUDD
Suffix:
Gender:M
Credentials:MA, LPC, CCM
Other - Prefix:
Other - First Name:JEREMY
Other - Middle Name:DANIEL
Other - Last Name:RUDD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA LPC CCM
Mailing Address - Street 1:5105 REED DR
Mailing Address - Street 2:
Mailing Address - City:THE COLONY
Mailing Address - State:TX
Mailing Address - Zip Code:75056-1240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7460 WARREN PKWY STE 100
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-4170
Practice Address - Country:US
Practice Address - Phone:214-484-7748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64960101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherN/A