Provider Demographics
NPI:1043713340
Name:POWELL, JAY ELDON
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:ELDON
Last Name:POWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 CROCKETT ST
Mailing Address - Street 2:
Mailing Address - City:MC GREGOR
Mailing Address - State:TX
Mailing Address - Zip Code:76657-1010
Mailing Address - Country:US
Mailing Address - Phone:254-462-4642
Mailing Address - Fax:
Practice Address - Street 1:13915 BURNET RD STE 303
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78728-6505
Practice Address - Country:US
Practice Address - Phone:512-996-9559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3034444164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse