Provider Demographics
NPI:1316552755
Name:MAYBERRY, JEANETTA
Entity Type:Individual
Prefix:
First Name:JEANETTA
Middle Name:
Last Name:MAYBERRY
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 1:103 E GLADIOLA ST
Mailing Address - Street 2:
Mailing Address - City:WHITE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75693-1707
Mailing Address - Country:US
Mailing Address - Phone:903-235-4741
Mailing Address - Fax:
Practice Address - Street 1:103 E GLADIOLA ST
Practice Address - Street 2:
Practice Address - City:WHITE OAK
Practice Address - State:TX
Practice Address - Zip Code:75693-1707
Practice Address - Country:US
Practice Address - Phone:903-235-4741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-12
Last Update Date:2020-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX982157163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice