Provider Demographics
NPI:1861913469
Name:JACK, CHERYL (LCDC)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:JACK
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3222 RIPPLING FALLS LN
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:TX
Mailing Address - Zip Code:77539-6175
Mailing Address - Country:US
Mailing Address - Phone:409-370-6482
Mailing Address - Fax:
Practice Address - Street 1:3201 FM 2004 RD
Practice Address - Street 2:
Practice Address - City:TEXAS CITY
Practice Address - State:TX
Practice Address - Zip Code:77591-2199
Practice Address - Country:US
Practice Address - Phone:409-944-4399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13802101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)