MEDICARE: MR. JACK ARNOLD WHITE L.P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	10607	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	84010L	OTHER	TX	BLUECROSS BLUESHIELD

General Provider Information

NPI Number	:	1053522383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACK ARNOLD WHITE L.P.C.

Provider Business Mailing Address
First Line	:	420 JACKSON KELLER RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-7147
Country	:	US
Telephone Number	:	210-377-3138
Fax Number	:

Provider Business Practice Location Address
First Line	:	420 JACKSON KELLER RD
Second Line	:	2255 HORAL
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-7147
Country	:	US
Telephone Number	:	210-377-3138
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2007
Last Update Date	:	07/08/2007

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