Provider Demographics
NPI:1811579683
Name:ELIZONDO, JACQUELINE ANN (LAT, OTC, ROT, OPE-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:ELIZONDO
Suffix:
Gender:F
Credentials:LAT, OTC, ROT, OPE-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6912 E FM 1729
Mailing Address - Street 2:
Mailing Address - City:IDALOU
Mailing Address - State:TX
Mailing Address - Zip Code:79329-6306
Mailing Address - Country:US
Mailing Address - Phone:210-421-4346
Mailing Address - Fax:
Practice Address - Street 1:4110 22ND PL
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1122
Practice Address - Country:US
Practice Address - Phone:806-792-4329
Practice Address - Fax:806-792-4329
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20-0612246ZX2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZX2200XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherOrthopedic Assistant