Provider Demographics
NPI:1649558602
Name:WHITING, DE'AUDRA JACKSON (LCDC)
Entity Type:Individual
Prefix:MS
First Name:DE'AUDRA
Middle Name:JACKSON
Last Name:WHITING
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 SAGEBRUSH LN
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:TX
Mailing Address - Zip Code:77354-1736
Mailing Address - Country:US
Mailing Address - Phone:832-659-1224
Mailing Address - Fax:
Practice Address - Street 1:402 SAGEBRUSH LN
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-1736
Practice Address - Country:US
Practice Address - Phone:832-659-1224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-25
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9347101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX9347OtherLICENSED CHEMICAL DEPENDENCY COUNSELOR