Provider Demographics
NPI:1437930930
Name:MOLINA VERGARA, JERUSHAH NICKELL (LPC-A)
Entity Type:Individual
Prefix:
First Name:JERUSHAH
Middle Name:NICKELL
Last Name:MOLINA VERGARA
Suffix:
Gender:F
Credentials:LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3463 LAKE AUSTIN BLVD APT C
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-5551
Mailing Address - Country:US
Mailing Address - Phone:859-771-6232
Mailing Address - Fax:
Practice Address - Street 1:7000 N MOPAC EXPY STE 200
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3013
Practice Address - Country:US
Practice Address - Phone:737-275-0030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX91424101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty