Healthcare Provider Details

I. General information

NPI: 1982208633
Provider Name (Legal Business Name): JENNIFER CAUDLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2020
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 W PEARL ST
GRANBURY TX
76048-2451
US

IV. Provider business mailing address

900 DART CT
GRANBURY TX
76049-1283
US

V. Phone/Fax

Practice location:
  • Phone: 817-578-0189
  • Fax:
Mailing address:
  • Phone: 817-578-0189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number80654
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: