Provider Demographics
NPI:1093178360
Name:LARUSSA, JACQUELYN (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:LARUSSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 WHITE WILLOW LN
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76002-4645
Mailing Address - Country:US
Mailing Address - Phone:985-790-2260
Mailing Address - Fax:
Practice Address - Street 1:1650 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051
Practice Address - Country:US
Practice Address - Phone:817-481-1588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-03
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS0492207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty