Provider Demographics
NPI:1902915861
Name:BANNIN, JACK (LMFT, LPC)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:BANNIN
Suffix:
Gender:M
Credentials:LMFT, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15403 AIROLE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-4013
Mailing Address - Country:US
Mailing Address - Phone:210-825-9969
Mailing Address - Fax:
Practice Address - Street 1:11230 WEST AVE STE 1203
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-1359
Practice Address - Country:US
Practice Address - Phone:210-320-2999
Practice Address - Fax:210-320-4716
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5072106H00000X
TX18744101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX163782902Medicaid