Provider Demographics
NPI:1871258152
Name:WELLBORN, JACQUELINE LOUISE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LOUISE
Last Name:WELLBORN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:WEATHERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:400 N BROWN ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:TX
Mailing Address - Zip Code:76531-1518
Mailing Address - Country:US
Mailing Address - Phone:254-386-1895
Mailing Address - Fax:
Practice Address - Street 1:104 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:HICO
Practice Address - State:TX
Practice Address - Zip Code:76457
Practice Address - Country:US
Practice Address - Phone:254-796-4224
Practice Address - Fax:866-264-2163
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-02
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX883588163W00000X
TX2021118463363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse