Healthcare Provider Details

I. General information

NPI: 1801548581
Provider Name (Legal Business Name): JESSICA MELISSA MANCILLAS-FLORES LPC-ASSCOCIATE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA FLORES LPC-ASSOCIATE

II. Dates (important events)

Enumeration Date: 01/24/2022
Last Update Date: 01/24/2022
Certification Date: 01/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 GRISSOM RD STE 103
SAN ANTONIO TX
78238-3024
US

IV. Provider business mailing address

PO BOX 564
HELOTES TX
78023-0564
US

V. Phone/Fax

Practice location:
  • Phone: 210-680-4747
  • Fax:
Mailing address:
  • Phone: 210-334-1245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number84874
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: