Provider Demographics
NPI:1346200649
Name:PERRY, JACQUELYN (DPM)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:
Last Name:PERRY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 RACE ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111-4116
Mailing Address - Country:US
Mailing Address - Phone:817-838-9424
Mailing Address - Fax:817-838-9425
Practice Address - Street 1:3020 RACE ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76111-4116
Practice Address - Country:US
Practice Address - Phone:817-838-9424
Practice Address - Fax:817-838-9425
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1244213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4407693OtherAETNA PPO
TX621526786OtherPHCS
TX621526786OtherUNITED HEALTHCARE
TX621526786OtherPACIFICARE/SECURE HORIZON
TX00L64NOtherBLUE CROSS BLUE SHEILD
TX018771801Medicaid
TX2097757OtherAETNA HMO
TX8F21962Medicare PIN
TX00L64NOtherBLUE CROSS BLUE SHEILD
TX480015334Medicare ID - Type UnspecifiedRAILROAD MEDICARE
TXU42519Medicare UPIN