Provider Demographics
NPI:1457946949
Name:JACK, EKAETTEELIZABETH E
Entity Type:Individual
Prefix:
First Name:EKAETTEELIZABETH
Middle Name:E
Last Name:JACK
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 1:3354 ROGERDALE RD APT 328
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042-5029
Mailing Address - Country:US
Mailing Address - Phone:832-546-9594
Mailing Address - Fax:
Practice Address - Street 1:3354 ROGERDALE RD APT 328
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042-5029
Practice Address - Country:US
Practice Address - Phone:832-546-9594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No343800000XTransportation ServicesSecured Medical Transport (VAN)
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)