Provider Demographics
NPI:1841781614
Name:VASSELL, JENNIFER (MA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:VASSELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 202
Mailing Address - Street 2:
Mailing Address - City:CIBOLO
Mailing Address - State:TX
Mailing Address - Zip Code:78108-0202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 W FM 78 STE 201
Practice Address - Street 2:
Practice Address - City:CIBOLO
Practice Address - State:TX
Practice Address - Zip Code:78108-3553
Practice Address - Country:US
Practice Address - Phone:210-727-5448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-28
Last Update Date:2020-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75828101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX388831501Medicaid