Provider Demographics
NPI:1972504967
Name:CARRUTHERS, JACQUELINE R (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:R
Last Name:CARRUTHERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17045 SAINT EDWARDS DR STE 302
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-1753
Mailing Address - Country:US
Mailing Address - Phone:713-694-6390
Mailing Address - Fax:713-694-5331
Practice Address - Street 1:17045 SAINT EDWARDS DR STE 302
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-1753
Practice Address - Country:US
Practice Address - Phone:713-694-6390
Practice Address - Fax:713-694-5331
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7429174400000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX152259103Medicaid
TX152259103Medicaid
TX8B1027Medicare PIN