Provider Demographics
NPI:1477314821
Name:JUSTICE, JAYDALINE NICKOLETTE
Entity Type:Individual
Prefix:
First Name:JAYDALINE
Middle Name:NICKOLETTE
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23975 HARDY OAK BLVD APT 4304
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78260-1555
Mailing Address - Country:US
Mailing Address - Phone:724-494-4168
Mailing Address - Fax:
Practice Address - Street 1:355 SPENCER LN STE 2
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78201-2056
Practice Address - Country:US
Practice Address - Phone:210-447-0039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor