Provider Demographics
NPI:1275048118
Name:RENNEBERG, JACQUELYN (APRN)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:RENNEBERG
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17201 I H 45 S
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77385-3311
Mailing Address - Country:US
Mailing Address - Phone:936-270-2099
Mailing Address - Fax:713-790-8703
Practice Address - Street 1:17201 I H 45 S
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77385-3311
Practice Address - Country:US
Practice Address - Phone:936-270-2099
Practice Address - Fax:713-790-8703
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP136074363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX380656401Medicaid