Provider Demographics
NPI:1891923017
Name:WHEAT, JACKIE MICHELLE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:MICHELLE
Last Name:WHEAT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:MICHELLE
Other - Last Name:MILHOLLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2715 1/2 9TH ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-3912
Mailing Address - Country:US
Mailing Address - Phone:940-631-1182
Mailing Address - Fax:940-767-2742
Practice Address - Street 1:2715 1/2 9TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-3912
Practice Address - Country:US
Practice Address - Phone:940-631-1182
Practice Address - Fax:940-767-2742
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX60591101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional