Provider Demographics
NPI:1538181813
Name:CHAVEZ, JACQUILIN (LPC)
Entity type:Individual
Prefix:
First Name:JACQUILIN
Middle Name:
Last Name:CHAVEZ
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 1:10008 PILOT AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79706-2615
Mailing Address - Country:US
Mailing Address - Phone:432-563-4144
Mailing Address - Fax:432-561-8611
Practice Address - Street 1:10008 PILOT AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79706-2615
Practice Address - Country:US
Practice Address - Phone:432-563-4144
Practice Address - Fax:432-561-8611
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-1115101Y00000X
TX66775101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ769721Medicaid