Healthcare Provider Details

I. General information

NPI: 1649910332
Provider Name (Legal Business Name): JESUSA ELENA JASSO LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 03/30/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12915 JONES MALTSBERGER RD STE 430
SAN ANTONIO TX
78247-4255
US

IV. Provider business mailing address

4633 BRANSCOMB DR
CORPUS CHRISTI TX
78411-2812
US

V. Phone/Fax

Practice location:
  • Phone: 361-000-0000
  • Fax:
Mailing address:
  • Phone: 361-445-6780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number74236
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: