Provider Demographics
NPI:1356103105
Name:MY FRIEND JACK'S HOUSE
Entity type:Organization
Organization Name:MY FRIEND JACK'S HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DONALDSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCDC, CFLE
Authorized Official - Phone:214-585-1414
Mailing Address - Street 1:PO BOX 1146
Mailing Address - Street 2:
Mailing Address - City:VAN ALSTYNE
Mailing Address - State:TX
Mailing Address - Zip Code:75495-1146
Mailing Address - Country:US
Mailing Address - Phone:214-585-1414
Mailing Address - Fax:
Practice Address - Street 1:2000 N MCDONALD ST STE 400
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071-3036
Practice Address - Country:US
Practice Address - Phone:214-585-1414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty