Provider Demographics
NPI:1710508635
Name:WITHERSPOON, JANA KAYE
Entity Type:Individual
Prefix:
First Name:JANA
Middle Name:KAYE
Last Name:WITHERSPOON
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 1:306 BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78374-1301
Mailing Address - Country:US
Mailing Address - Phone:870-577-3274
Mailing Address - Fax:
Practice Address - Street 1:306 BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TX
Practice Address - Zip Code:78374-1301
Practice Address - Country:US
Practice Address - Phone:870-577-3274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-01
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX227133163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO080581114OtherDRIVERS LICENSE