Provider Demographics
NPI:1750471629
Name:DOUGLAS, JIMMY WAYNE (LPC)
Entity type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:WAYNE
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:MR
Other - First Name:JIM
Other - Middle Name:W
Other - Last Name:DOUGLAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:520 WEST BIRGE STREET
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75092
Mailing Address - Country:US
Mailing Address - Phone:903-868-2133
Mailing Address - Fax:903-891-3378
Practice Address - Street 1:812 EAST PECAN GROVE ROAD
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090
Practice Address - Country:US
Practice Address - Phone:903-868-2133
Practice Address - Fax:903-891-3378
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14507101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX02761501Medicaid