Healthcare Provider Details

I. General information

NPI: 1235833898
Provider Name (Legal Business Name): JACOB GILLETTE LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 S AUSTIN ST
AMARILLO TX
79106-6714
US

IV. Provider business mailing address

1110 BROADMOOR ST
AMARILLO TX
79106-5531
US

V. Phone/Fax

Practice location:
  • Phone: 806-437-2360
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number91314
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: