Provider Demographics
NPI:1508027004
Name:HANNA, JACQUELINE R (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:R
Last Name:HANNA
Suffix:
Gender:F
Credentials:MD
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 99213
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0213
Mailing Address - Country:US
Mailing Address - Phone:682-885-4446
Mailing Address - Fax:817-810-1396
Practice Address - Street 1:2727 E SOUTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6613
Practice Address - Country:US
Practice Address - Phone:682-885-6000
Practice Address - Fax:682-885-6026
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9871208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics