=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134589328
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JENNIFER A. FORSBERG, PH.D., PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2016
-----------------------------------------------------
Last Update Date | 03/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8800 VILLAGE DR SUITE 209
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78217-5412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-202-0100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8800 VILLAGE DR SUITE 209
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78217-5412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-202-0100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JENNIFER FORSBERG
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 512-636-9770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | 32478
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------