Healthcare Provider Details

I. General information

NPI: 1154591584
Provider Name (Legal Business Name): JEANETTE ANN WEEMS LPC-S, CRC, MEDIATOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/29/2008
Last Update Date: 09/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 RAY WHITE RD STE 200
FORT WORTH TX
76244
US

IV. Provider business mailing address

9500 RAY WHITE RD STE 200
FORT WORTH TX
76244-9105
US

V. Phone/Fax

Practice location:
  • Phone: 214-228-3916
  • Fax: 855-529-3367
Mailing address:
  • Phone: 214-228-3916
  • Fax: 855-529-3367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number20126
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number20126
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: