Provider Demographics
NPI:1730306572
Name:ANDREW, JACLYN JO
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:JO
Last Name:ANDREW
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 1:5238 SUNNYBROOK LN
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-3497
Mailing Address - Country:US
Mailing Address - Phone:940-642-2193
Mailing Address - Fax:
Practice Address - Street 1:4600 TAFT BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-4935
Practice Address - Country:US
Practice Address - Phone:940-691-1710
Practice Address - Fax:940-691-2193
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111348174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist