Provider Demographics
NPI: | 1770637704 |
---|---|
Name: | FORT, JENNIFER ANN (LPC, LMFT) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | JENNIFER |
Middle Name: | ANN |
Last Name: | FORT |
Suffix: | |
Gender: | F |
Credentials: | LPC, LMFT |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 608 NEWHAVEN ST |
Mailing Address - Street 2: | |
Mailing Address - City: | VICTORIA |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 77904-2558 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 361-575-2796 |
Mailing Address - Fax: | 361-575-2796 |
Practice Address - Street 1: | 608 NEWHAVEN ST |
Practice Address - Street 2: | |
Practice Address - City: | VICTORIA |
Practice Address - State: | TX |
Practice Address - Zip Code: | 77904-2558 |
Practice Address - Country: | US |
Practice Address - Phone: | 361-575-2796 |
Practice Address - Fax: | 361-575-2796 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2007-01-23 |
Last Update Date: | 2007-07-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | 19184 | 101YP2500X |
TX | 5124 | 106H00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Not Answered | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional |
Not Answered | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 6642LC | Other | BLUE CROSS BLUE SHIELD |