Provider Demographics
NPI:1821135195
Name:MACH, JEAN ELICK (LPC, ATR)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:ELICK
Last Name:MACH
Suffix:
Gender:F
Credentials:LPC, ATR
Other - Prefix:MRS
Other - First Name:JEAN
Other - Middle Name:ELICK
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 W. DAVIS STREET
Mailing Address - Street 2:SUITE 250
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304
Mailing Address - Country:US
Mailing Address - Phone:832-401-9701
Mailing Address - Fax:832-565-1010
Practice Address - Street 1:3500 W. DAVIS STREET
Practice Address - Street 2:SUITE 250
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304
Practice Address - Country:US
Practice Address - Phone:832-401-9701
Practice Address - Fax:832-565-1010
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
97-040221700000X
TX14157101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1810749-01Medicaid