Provider Demographics
NPI:1265139505
Name:ESTRACA, JAQUELINE MARIE
Entity type:Individual
Prefix:
First Name:JAQUELINE
Middle Name:MARIE
Last Name:ESTRACA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4115 MISTFLOWER DR
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-3553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4115 MISTFLOWER DR
Practice Address - Street 2:
Practice Address - City:CONVERSE
Practice Address - State:TX
Practice Address - Zip Code:78109-3553
Practice Address - Country:US
Practice Address - Phone:361-813-0252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX89324101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional