MEDICARE: CHERYL JACK LCDC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	13802	TX

General Provider Information

NPI Number	:	1861913469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHERYL JACK LCDC

Provider Business Mailing Address
First Line	:	3222 RIPPLING FALLS LN
Second Line	:
City	:	DICKINSON
State	:	TX
Zip	:	77539-6175
Country	:	US
Telephone Number	:	409-370-6482
Fax Number	:

Provider Business Practice Location Address
First Line	:	3201 FM 2004 RD
Second Line	:
City	:	TEXAS CITY
State	:	TX
Zip	:	77591-2199
Country	:	US
Telephone Number	:	409-944-4399
Fax Number	:

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

Provider Enumeration Date	:	07/05/2017
Last Update Date	:	07/05/2017

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