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General NPI Number Information
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NPI Number | 1235420076
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Entity Type | Organization
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Legal Business Name | MONTGOMERY BEHAVIORAL HEALTH INSTITUTE, LLC
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Dates
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Enumeration Date | 04/27/2011
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Last Update Date | 03/23/2012
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Provider Practice Location Address
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Address Line | 2506 S LANCASTER RD
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City | DALLAS
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State | TX
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Zip | 75216-2532
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Country | US
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Telephone | 214-356-0335
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Fax |
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Provider Business Mailing Address
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Address Line | 4447 N CENTRAL EXPY SUITE 110 PMB 231
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City | DALLAS
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State | TX
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Zip | 75205-4245
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | DR. TERESA L. JACKSON
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Credential | PSY.D.
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Telephone | 214-356-0335
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 34857
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License Number State | TX
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