=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811441165
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JJJ COUNSELING & ASSOCIATES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2016
-----------------------------------------------------
Last Update Date | 12/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 S 14TH ST SUITE 140
-----------------------------------------------------
City | MIDLOTHIAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76065-3358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-913-0419
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 691
-----------------------------------------------------
City | EULESS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76039-0691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-913-0419
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | MS. JESSICA GURAL
-----------------------------------------------------
Credential | LPC, LCDCI
-----------------------------------------------------
Telephone | 817-913-0419
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 71286
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------