Provider Demographics
NPI:1710190574
Name:BUCK, JAN M (LPC)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:M
Last Name:BUCK
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 1:209 W. 2ND STREET
Mailing Address - Street 2:SUITE 128
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111
Mailing Address - Country:US
Mailing Address - Phone:817-680-3942
Mailing Address - Fax:
Practice Address - Street 1:2900 HWY 121
Practice Address - Street 2:SUITE 140
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021
Practice Address - Country:US
Practice Address - Phone:817-680-3942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16585101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional