Provider Demographics
NPI:1750821633
Name:AVILA, JEANINE
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:
Last Name:AVILA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JEANINE
Other - Middle Name:
Other - Last Name:VILLANUEVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:117 LONE SHADOW DR
Mailing Address - Street 2:
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-2523
Mailing Address - Country:US
Mailing Address - Phone:808-585-1560
Mailing Address - Fax:
Practice Address - Street 1:2511 TRIMMIER RD
Practice Address - Street 2:SUITE 140
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-1908
Practice Address - Country:US
Practice Address - Phone:866-273-2451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIH01330250106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1396198459OtherTRICARE PRIME