Provider Demographics
NPI:1063432136
Name:POOL, JESSE DAVID (LPC)
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:DAVID
Last Name:POOL
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5133 ROYCE DR
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79110-3010
Mailing Address - Country:US
Mailing Address - Phone:806-584-5400
Mailing Address - Fax:806-359-0610
Practice Address - Street 1:3611 SONCY, SUITE 4A
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79119
Practice Address - Country:US
Practice Address - Phone:806-584-5400
Practice Address - Fax:806-359-0610
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17282101YM0800X, 101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1493348-01Medicaid