Provider Demographics
NPI:1164506796
Name:WEATHERLY, JACQUELINE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:WEATHERLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4439
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4439
Mailing Address - Country:US
Mailing Address - Phone:713-792-2991
Mailing Address - Fax:
Practice Address - Street 1:1515 HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4009
Practice Address - Country:US
Practice Address - Phone:713-792-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04999363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00391466OtherRR MEDICARE
TX8Y0794OtherBCBS
TX194650101Medicaid
TX8J3149Medicare PIN