Provider Demographics
NPI:1922872209
Name:TAYLOR, JACK KENNEDY (LPC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:KENNEDY
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:KENNEDY
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 1262
Mailing Address - Street 2:
Mailing Address - City:LYTLE
Mailing Address - State:TX
Mailing Address - Zip Code:78052-1262
Mailing Address - Country:US
Mailing Address - Phone:512-755-0521
Mailing Address - Fax:
Practice Address - Street 1:19971 FM 3175
Practice Address - Street 2:
Practice Address - City:LYTLE
Practice Address - State:TX
Practice Address - Zip Code:78052-3481
Practice Address - Country:US
Practice Address - Phone:512-755-0521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX87648101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health