Provider Demographics
NPI:1902188444
Name:BLACK-JACOBS, KENYATTA (MA, LPC)
Entity Type:Individual
Prefix:
First Name:KENYATTA
Middle Name:
Last Name:BLACK-JACOBS
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 SOTOGRANDE ST
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-4456
Mailing Address - Country:US
Mailing Address - Phone:214-298-2780
Mailing Address - Fax:
Practice Address - Street 1:3939 W GREEN OAKS BLVD STE 214
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76016-2793
Practice Address - Country:US
Practice Address - Phone:214-298-2780
Practice Address - Fax:214-380-4965
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-11
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66056101YP2500X
TX251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional