Provider Demographics
NPI:1437314697
Name:LAFONTAINE-MACK, JEANNETTE DIANNE (LPC)
Entity Type:Individual
Prefix:MS
First Name:JEANNETTE
Middle Name:DIANNE
Last Name:LAFONTAINE-MACK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 LANSDALE DR
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75116-4411
Mailing Address - Country:US
Mailing Address - Phone:214-226-9187
Mailing Address - Fax:972-296-5313
Practice Address - Street 1:402 W WHEATLAND RD
Practice Address - Street 2:SUITE 160
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-4600
Practice Address - Country:US
Practice Address - Phone:214-226-9187
Practice Address - Fax:972-296-5313
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-26
Last Update Date:2008-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15077101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional