Provider Demographics
NPI:1912368143
Name:JACQUET, ANTALISHA
Entity Type:Individual
Prefix:
First Name:ANTALISHA
Middle Name:
Last Name:JACQUET
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 1:2921 SYCAMORE SPRINGS DRIVE
Mailing Address - Street 2:SUITE NUMBER 179
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339
Mailing Address - Country:US
Mailing Address - Phone:346-804-1015
Mailing Address - Fax:
Practice Address - Street 1:2921 SYCAMORE SPRINGS DR
Practice Address - Street 2:SUITE NUMBER 179
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-1330
Practice Address - Country:US
Practice Address - Phone:346-804-1015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child