=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669986519
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACY RADER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2017
-----------------------------------------------------
Last Update Date | 11/29/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9026 GARLAND RD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75218-3919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-880-4383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2362 OLDBRIDGE DR
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75228-5360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-880-4383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | JACY RADER
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 817-880-4383
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 73765
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------