Provider Demographics
NPI:1497865984
Name:SWANSON, JACK PETER (LCSW)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:PETER
Last Name:SWANSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9401 SOUTHWEST FWY
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77074-1407
Mailing Address - Country:US
Mailing Address - Phone:713-970-7000
Mailing Address - Fax:713-970-7246
Practice Address - Street 1:9401 SOUTHWEST FWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-1407
Practice Address - Country:US
Practice Address - Phone:713-970-7000
Practice Address - Fax:713-970-7246
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175769201Medicaid
TX8D8277Medicare ID - Type Unspecified
TXQ50436Medicare UPIN