Provider Demographics
NPI:1275937153
Name:GARVIN, JACQUELYN RACHELLE (PA)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:RACHELLE
Last Name:GARVIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:RACHELLE
Other - Last Name:TRICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2900 N INTERSTATE 35 STE 210
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-5145
Mailing Address - Country:US
Mailing Address - Phone:940-323-3440
Mailing Address - Fax:
Practice Address - Street 1:10840 TEXAS HEALTH TRL STE 110
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6847
Practice Address - Country:US
Practice Address - Phone:682-212-6437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09484363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX564488YKP5Medicare PIN