Provider Demographics
NPI:1962907329
Name:PRUITT, JENNIFER (LPC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4704 ARGYLE LN
Mailing Address - Street 2:
Mailing Address - City:ARGYLE
Mailing Address - State:TX
Mailing Address - Zip Code:76226-1517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:630 E SOUTHLAKE BLVD STE 112
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6259
Practice Address - Country:US
Practice Address - Phone:214-494-6287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX74770OtherTEXAS STATE BOARD OF EXAMINERS