Provider Demographics
NPI:1710394663
Name:KRUSE, JENNIFER (LPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KRUSE
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 1:2140 E SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE L, 687
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6516
Mailing Address - Country:US
Mailing Address - Phone:817-371-0863
Mailing Address - Fax:
Practice Address - Street 1:2140 E SOUTHLAKE BLVD
Practice Address - Street 2:SUITE L, 687
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6516
Practice Address - Country:US
Practice Address - Phone:817-371-0863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-11
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67477101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional