Provider Demographics
NPI:1255870226
Name:STREET, JACQUELINE BREANN (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:BREANN
Last Name:STREET
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 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-2987
Practice Address - Street 1:4708 ALLIANCE BLVD STE 750
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5354
Practice Address - Country:US
Practice Address - Phone:972-562-5999
Practice Address - Fax:972-562-9755
Is Sole Proprietor?:No
Enumeration Date:2017-02-23
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11198363AM0700X
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX368884801Medicaid
TXP01833670OtherRAILROAD
TX564524YKYCMedicare PIN