Provider Demographics
NPI:1720587173
Name:SHOTWELL, JENNIFER CUMMINGS (LCDC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CUMMINGS
Last Name:SHOTWELL
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 1:6472 TRAMMEL DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-2219
Mailing Address - Country:US
Mailing Address - Phone:713-557-8430
Mailing Address - Fax:
Practice Address - Street 1:2626 COLE AVE STE 300
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-1094
Practice Address - Country:US
Practice Address - Phone:713-557-8430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14218101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)