Provider Demographics
NPI:1588437834
Name:SAMUEL, JENNIFER (LPC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:NA
Other - Middle Name:
Other - Last Name:NA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1877 PARK ST
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-3743
Mailing Address - Country:US
Mailing Address - Phone:817-374-4401
Mailing Address - Fax:
Practice Address - Street 1:4200 S HULEN ST STE 450
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4910
Practice Address - Country:US
Practice Address - Phone:817-374-4401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82913101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health