Provider Demographics
NPI:1780305102
Name:WILLISTON, JACQUELINE MARY (LPC, LCDC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARY
Last Name:WILLISTON
Suffix:
Gender:F
Credentials:LPC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 CLINIC DR STE A110
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76039-7453
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:173 W MAIN ST STE 6
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-3117
Practice Address - Country:US
Practice Address - Phone:817-381-2290
Practice Address - Fax:888-909-5191
Is Sole Proprietor?:No
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15454101YA0400X
TX85356101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)