Provider Demographics
NPI:1053522383
Name:WHITE, JACK ARNOLD (LPC)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:ARNOLD
Last Name:WHITE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 JACKSON KELLER RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-7147
Mailing Address - Country:US
Mailing Address - Phone:210-377-3138
Mailing Address - Fax:
Practice Address - Street 1:420 JACKSON KELLER RD
Practice Address - Street 2:2255 HORAL
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-7147
Practice Address - Country:US
Practice Address - Phone:210-377-3138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10607101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84010LOtherBLUECROSS BLUESHIELD