Provider Demographics
NPI:1801452396
Name:MANLEY, JACQUELINE ANN (LMFT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:MANLEY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10016 SHELBURNE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-8524
Mailing Address - Country:US
Mailing Address - Phone:619-818-6516
Mailing Address - Fax:
Practice Address - Street 1:9800 HILLWOOD PKWY STE 140
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-1532
Practice Address - Country:US
Practice Address - Phone:619-818-6516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-10
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103200106H00000X
TX203440106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist