Healthcare Provider Details

I. General information

NPI: 1710570775
Provider Name (Legal Business Name): VIVIAN JONES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2021
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5751 KROGER DR STE 114
FORT WORTH TX
76244-5633
US

IV. Provider business mailing address

5613 TRAVELLER DR
NORTH RICHLAND HILLS TX
76180-2037
US

V. Phone/Fax

Practice location:
  • Phone: 682-593-1402
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number97371
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: