=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184008161
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J10 INTERNATIONAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2015
-----------------------------------------------------
Last Update Date | 08/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 PAT BOOKER RD SUITE 208
-----------------------------------------------------
City | UNIVERSAL CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78148-4154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-885-0082
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 PAT BOOKER RD SUITE 208
-----------------------------------------------------
City | UNIVERSAL CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78148-4154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-885-0082
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | MS. JOCELYN MONICA JOHNSON
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 210-885-0082
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | 70567
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 70567
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------