The Magnolia Clinic, LLC

Primary specialty

Marriage & Family TherapistTaxonomy code 106H00000X

Legal business name

THE MAGNOLIA CLINIC, LLC

Practice address

1124 Galveston Ave Ste B
Fort Worth, TX 76104-4878

Phone

(817) 609-2289

NPI assigned

Oct 19, 2021

Last updated

Oct 19, 2021By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Jacob WasongaNPI 1861043713

Title

Owner

Phone

(817) 609-2289

Specialties & licenses 1

Addresses

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Jacob O Wasonga, PH.D, LMFT

  • Marriage & Family Therapist
  • Fort Worth, TX
  • NPI 1861043713
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1634601600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1634601600000",
    "number": "1629731302",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 592732",
            "city": "SAN ANTONIO",
            "state": "TX",
            "postal_code": "782590186",
            "telephone_number": "817-609-2289"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1124 GALVESTON AVE STE B",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "761044878",
            "telephone_number": "817-609-2289"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THE MAGNOLIA CLINIC, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-10-19",
        "last_updated": "2021-10-19",
        "certification_date": "2021-10-19",
        "status": "A",
        "authorized_official_last_name": "WASONGA",
        "authorized_official_first_name": "JACOB",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "817-609-2289"
    },
    "taxonomies": [
        {
            "code": "106H00000X",
            "taxonomy_group": "",
            "desc": "Marriage & Family Therapist",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Marriage & Family Therapist in Fort Worth, TX
• Providers in Fort Worth, TX by specialty
• Marriage & Family Therapist in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 19, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.