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General NPI Number Information
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NPI Number | 1003603002
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Entity Type | Individual
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Provider Name | JACY BLAKE FISETTE
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Gender | Female
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Dates
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Enumeration Date | 04/22/2025
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Last Update Date | 04/22/2025
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Provider Practice Location Address
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Address Line | 2604 COLQUITT CV # B
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City | AUSTIN
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State | TX
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Zip | 78748-5952
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Country | US
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Telephone | 512-809-4757
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Fax |
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Provider Business Mailing Address
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Address Line | 2604 COLQUITT CV # B
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City | AUSTIN
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State | TX
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Zip | 78748-5952
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Country | US
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Telephone | 512-809-4757
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 95636
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License Number State | TX
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