Provider Demographics
NPI:1457436032
Name:HENNEBURG, JAMES VINCENT JR (LPC)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:VINCENT
Last Name:HENNEBURG
Suffix:JR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6090 SURETY DRIVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-2060
Mailing Address - Country:US
Mailing Address - Phone:915-778-3807
Mailing Address - Fax:915-779-6600
Practice Address - Street 1:6090 SURETY DRIVE
Practice Address - Street 2:SUITE 105
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2060
Practice Address - Country:US
Practice Address - Phone:915-778-3807
Practice Address - Fax:915-779-6600
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13071101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX095516302Medicaid
TX83775LOtherBLUE CROSS PROVIDER