Provider Demographics
NPI:1376398271
Name:PACK, JOHN DAVID (MS, LPC, LCDC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:PACK
Suffix:
Gender:M
Credentials:MS, LPC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 W 16TH AVE APT 107
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79102-2245
Mailing Address - Country:US
Mailing Address - Phone:806-543-1483
Mailing Address - Fax:
Practice Address - Street 1:5700 ENTERPRISE CIR STE 113
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-4634
Practice Address - Country:US
Practice Address - Phone:806-599-3424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15849101YA0400X
TX85025101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)