Provider Demographics
NPI:1518569201
Name:LAYNE, JACQLYN DANIELLE
Entity Type:Individual
Prefix:
First Name:JACQLYN
Middle Name:DANIELLE
Last Name:LAYNE
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 1:1710 OLD ALVIN RD APT 9203
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581-3012
Mailing Address - Country:US
Mailing Address - Phone:281-772-3422
Mailing Address - Fax:
Practice Address - Street 1:1075 KINGWOOD DR STE 204
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-3000
Practice Address - Country:US
Practice Address - Phone:281-772-3422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX79341101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor