Provider Demographics
NPI:1861043713
Name:WASONGA, JACOB O (PHD, LMFT)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:O
Last Name:WASONGA
Suffix:
Gender:M
Credentials:PHD, LMFT
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 592732
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78259-0186
Mailing Address - Country:US
Mailing Address - Phone:817-609-2289
Mailing Address - Fax:
Practice Address - Street 1:1124 GALVESTON AVE STE B
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4878
Practice Address - Country:US
Practice Address - Phone:210-420-8117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX203024106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty