Provider Demographics
NPI:1821871278
Name:RUTINWA, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:RUTINWA
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 1:7600 HIGHMEADOW DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-4825
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1505 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-2277
Practice Address - Country:US
Practice Address - Phone:857-237-5816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2023101720363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health