Provider Demographics
NPI:1003981663
Name:WANEBO, JACKIE E (MD)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:E
Last Name:WANEBO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7900 FANNIN ST
Mailing Address - Street 2:SUITE #3300
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-2934
Mailing Address - Country:US
Mailing Address - Phone:713-630-0660
Mailing Address - Fax:713-796-2555
Practice Address - Street 1:7900 FANNIN ST
Practice Address - Street 2:SUITE #3300
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-2934
Practice Address - Country:US
Practice Address - Phone:713-630-0660
Practice Address - Fax:713-796-2555
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXJ9428208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127069603Medicaid