Provider Demographics
NPI:1851558639
Name:MOUTON, JACQUELINE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:MOUTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21216 NORTHWEST FWY
Mailing Address - Street 2:SUITE 620
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-1439
Mailing Address - Country:US
Mailing Address - Phone:281-469-7704
Mailing Address - Fax:281-469-4066
Practice Address - Street 1:21216 NORTHWEST FWY
Practice Address - Street 2:SUITE 620
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-1439
Practice Address - Country:US
Practice Address - Phone:281-469-7704
Practice Address - Fax:281-469-4066
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00854363AM0700X
TXPA05855363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical