Provider Demographics
NPI:1760088876
Name:FARIAS, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:FARIAS
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 1:1885 EL PASEO ST APT 634
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-3046
Mailing Address - Country:US
Mailing Address - Phone:940-594-8817
Mailing Address - Fax:
Practice Address - Street 1:6720 BERTNER AVE
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2604
Practice Address - Country:US
Practice Address - Phone:832-355-4214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX902067163WM0705X
TX1040090363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical