Provider Demographics
NPI:1922459858
Name:GARCIA, JAZLENE
Entity Type:Individual
Prefix:
First Name:JAZLENE
Middle Name:
Last Name:GARCIA
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 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-0996
Practice Address - Street 1:613 ELIZABETH ST
Practice Address - Street 2:STE 804
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2220
Practice Address - Country:US
Practice Address - Phone:361-881-3351
Practice Address - Fax:361-861-9022
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-22
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX577227363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX366195101Medicaid
TX540037YMJMMedicare PIN