Provider Demographics
NPI:1104385616
Name:SONNY, JASIME
Entity Type:Individual
Prefix:
First Name:JASIME
Middle Name:
Last Name:SONNY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10333 HARWIN DR STE 167
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77036-1561
Mailing Address - Country:US
Mailing Address - Phone:346-571-5688
Mailing Address - Fax:
Practice Address - Street 1:10333 HARWIN DR STE 167
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77036-1561
Practice Address - Country:US
Practice Address - Phone:346-571-5688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-14
Last Update Date:2019-04-25
Deactivation Date:2019-03-14
Deactivation Code:
Reactivation Date:2019-04-24
Provider Licenses
StateLicense IDTaxonomies
TX171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171MOOOOOXMedicaid