Provider Demographics
NPI:1356794200
Name:LEYVA, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:LEYVA
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 1:7323 WASHITA WAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78256
Mailing Address - Country:US
Mailing Address - Phone:210-410-0325
Mailing Address - Fax:210-579-6932
Practice Address - Street 1:16350 BLANCO RD
Practice Address - Street 2:SUITE 110B
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-3339
Practice Address - Country:US
Practice Address - Phone:210-764-2121
Practice Address - Fax:210-579-6932
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-15
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT117769225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist