Healthcare Provider Details

I. General information

NPI: 1144666975
Provider Name (Legal Business Name): JACKIE SWOPE LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2013
Last Update Date: 05/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8956 RESEARCH BLVD BLDG 2
AUSTIN TX
78758-5902
US

IV. Provider business mailing address

8956 RESEARCH BLVD BLDG 2
AUSTIN TX
78758-5902
US

V. Phone/Fax

Practice location:
  • Phone: 512-451-7337
  • Fax: 512-451-8729
Mailing address:
  • Phone: 512-451-7337
  • Fax: 512-451-8729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number66917
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: