Provider Demographics
NPI:1679445464
Name:MOBLEY, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:MOBLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76701-1252
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:811 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76701-1252
Practice Address - Country:US
Practice Address - Phone:254-307-2107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-22
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker