Provider Demographics
NPI:1902636202
Name:JONTRA, JACKSON
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:JONTRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6061 VILLAGE BEND DR APT 1105
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-3554
Mailing Address - Country:US
Mailing Address - Phone:903-330-3582
Mailing Address - Fax:
Practice Address - Street 1:420 HAWKINS RUN RD STE 100
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-6654
Practice Address - Country:US
Practice Address - Phone:214-530-2335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor