Provider Demographics
NPI:1477828127
Name:MASCORRO, JEANNA MICHELLE (DPM)
Entity type:Individual
Prefix:DR
First Name:JEANNA
Middle Name:MICHELLE
Last Name:MASCORRO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1553
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77553
Mailing Address - Country:US
Mailing Address - Phone:409-405-1977
Mailing Address - Fax:409-405-1728
Practice Address - Street 1:4920 SEAWALL BLVD
Practice Address - Street 2:STE B
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77551-6011
Practice Address - Country:US
Practice Address - Phone:409-405-1977
Practice Address - Fax:409-405-1728
Is Sole Proprietor?:No
Enumeration Date:2012-03-14
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT16-2011390200000X
TX2016213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program