Provider Demographics
NPI:1609417708
Name:WESLEY, JACQUELINE (LPC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:WESLEY
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 1:1919 JACKSON ST APT 1512
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-4947
Mailing Address - Country:US
Mailing Address - Phone:214-395-2085
Mailing Address - Fax:
Practice Address - Street 1:1919 JACKSON ST APT 1512
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-4947
Practice Address - Country:US
Practice Address - Phone:214-405-1624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-01
Last Update Date:2022-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX84083101YP2500X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician