Provider Demographics
NPI:1063922847
Name:RADER, JACY (LPC-INTERN)
Entity type:Individual
Prefix:
First Name:JACY
Middle Name:
Last Name:RADER
Suffix:
Gender:F
Credentials:LPC-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2362 OLDBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75228-5360
Mailing Address - Country:US
Mailing Address - Phone:817-880-4383
Mailing Address - Fax:
Practice Address - Street 1:9026 GARLAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75218-3919
Practice Address - Country:US
Practice Address - Phone:817-880-4383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73765101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty