=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124354469
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER BROOKE URBAN LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2009
-----------------------------------------------------
Last Update Date | 10/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1022 GARNER FIELD RD SUITE C
-----------------------------------------------------
City | UVALDE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78801-4867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-486-0960
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1521
-----------------------------------------------------
City | CARRIZO SPRINGS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78834-7521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-255-0455
-----------------------------------------------------
Fax | 830-876-0061
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 41416
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------