=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598005183
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACOBS LADDER PSYCHOLOGICAL SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2013
-----------------------------------------------------
Last Update Date | 05/13/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11201 RICHMOND AVE SUITE A-100A
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77082-6653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-512-4734
-----------------------------------------------------
Fax | 281-494-8380
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16823 GREEN QUAIL DR
-----------------------------------------------------
City | MISSOURI CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77489-5301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-512-4734
-----------------------------------------------------
Fax | 281-497-8380
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PRESIDENT
-----------------------------------------------------
Name | KEISHA HOLLEY JOHNSON
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 281-785-7528
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 35188
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------