Provider Demographics
NPI:1710045034
Name:JACK, APRIL RENEE
Entity Type:Individual
Prefix:
First Name:APRIL
Middle Name:RENEE
Last Name:JACK
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 1:10010 SAGEDOWNE LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77089-4312
Mailing Address - Country:US
Mailing Address - Phone:832-643-9739
Mailing Address - Fax:281-922-6352
Practice Address - Street 1:10010 SAGEDOWNE LN
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77089-4312
Practice Address - Country:US
Practice Address - Phone:832-643-9739
Practice Address - Fax:281-922-6352
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38266171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1801011Medicaid