Provider Demographics
NPI:1093168049
Name:CHILDREN'S CLINIC OF JASPER
Entity Type:Organization
Organization Name:CHILDREN'S CLINIC OF JASPER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERE
Authorized Official - Middle Name:
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-634-2214
Mailing Address - Street 1:PO BOX 150638
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75915-0638
Mailing Address - Country:US
Mailing Address - Phone:936-634-2214
Mailing Address - Fax:936-639-9660
Practice Address - Street 1:1008 DICKERSON DR
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-5111
Practice Address - Country:US
Practice Address - Phone:936-634-2214
Practice Address - Fax:936-639-9660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4321208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX191679301Medicaid
MD092130602Medicaid