Provider Demographics
NPI:1386963726
Name:PICKENS, JOHN (LCDC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PICKENS
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 JEALOUSE WAY
Mailing Address - Street 2:SUITE 113
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-2577
Mailing Address - Country:US
Mailing Address - Phone:972-291-2929
Mailing Address - Fax:972-291-2949
Practice Address - Street 1:625 JEALOUSE WAY
Practice Address - Street 2:SUITE 113
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-2577
Practice Address - Country:US
Practice Address - Phone:972-291-2929
Practice Address - Fax:972-291-2949
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9189101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)