Healthcare Provider Details

I. General information

NPI: 1720728108
Provider Name (Legal Business Name): JESSICA DURHAM MS, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2022
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 VALLEY VW
GLEN ROSE TX
76043-4320
US

IV. Provider business mailing address

120 VALLEY VW
GLEN ROSE TX
76043-4320
US

V. Phone/Fax

Practice location:
  • Phone: 832-819-2755
  • Fax:
Mailing address:
  • Phone: 936-230-8077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number81283
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: