Provider Demographics
NPI:1013949510
Name:PERSELLIN, JAMIE (LCSW)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:PERSELLIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 WESTHEIMER RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-4414
Mailing Address - Country:US
Mailing Address - Phone:713-850-0049
Mailing Address - Fax:713-850-0036
Practice Address - Street 1:4150 WESTHEIMER RD
Practice Address - Street 2:SUITE 103
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-4414
Practice Address - Country:US
Practice Address - Phone:713-850-0049
Practice Address - Fax:713-850-0036
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS183171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G3672Medicare ID - Type UnspecifiedMCR SA
TXR80448Medicare UPIN