=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891403069
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACY HOOTEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2022
-----------------------------------------------------
Last Update Date | 11/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2920 OAK PARK CIR STE 102
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76109-1853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-865-5381
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 213 DONALD ST
-----------------------------------------------------
City | WHITE SETTLEMENT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76108-2119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-629-0476
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 88766
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------