Provider Demographics
NPI:1306345293
Name:OTTO, JAQUI
Entity type:Individual
Prefix:
First Name:JAQUI
Middle Name:
Last Name:OTTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1664 KELLER PARKWAY STE 102
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248
Mailing Address - Country:US
Mailing Address - Phone:817-492-5105
Mailing Address - Fax:
Practice Address - Street 1:1664 KELLER PARKWAY STE 102
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248
Practice Address - Country:US
Practice Address - Phone:817-492-5105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-06
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32976103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist