Healthcare Provider Details

I. General information

NPI: 1982517090
Provider Name (Legal Business Name): JEANNIE MATA LPC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

5751 KROGER DR STE 260
FORT WORTH TX
76244-5650
US

IV. Provider business mailing address

6332 MEADOW LAKES DR
N RICHLAND HILLS TX
76180-7802
US

V. Phone/Fax

Practice location:
  • Phone: 817-366-0053
  • Fax:
Mailing address:
  • Phone: 817-366-0053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number101415
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: