Provider Demographics
NPI:1992483887
Name:RASBERRY, JAKE
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:RASBERRY
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 1:11754 JOLLYVILLE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-3948
Mailing Address - Country:US
Mailing Address - Phone:512-331-2700
Mailing Address - Fax:
Practice Address - Street 1:11754 JOLLYVILLE RD STE 110
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-3948
Practice Address - Country:US
Practice Address - Phone:512-331-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX86392101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health