Provider Demographics
NPI:1699273649
Name:LACY, JENNIFER DIANNE (LPC-A)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIANNE
Last Name:LACY
Suffix:
Gender:
Credentials:LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2452 MUSCOVY DR
Mailing Address - Street 2:
Mailing Address - City:COPPERAS COVE
Mailing Address - State:TX
Mailing Address - Zip Code:76522-9736
Mailing Address - Country:US
Mailing Address - Phone:850-259-0269
Mailing Address - Fax:
Practice Address - Street 1:1705 S FORT HOOD ST STE 103B
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-1681
Practice Address - Country:US
Practice Address - Phone:254-239-1027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1848404106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician