Healthcare Provider Details

I. General information

NPI: 1033046065
Provider Name (Legal Business Name): JERRICA NICOLE MAXEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 E MARSHALL AVE STE 5003
LONGVIEW TX
75601-5530
US

IV. Provider business mailing address

419 MARGIE BUSH RD
HALLSVILLE TX
75650-7701
US

V. Phone/Fax

Practice location:
  • Phone: 903-470-7117
  • Fax:
Mailing address:
  • Phone: 903-452-0340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number98406
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: