Provider Demographics
NPI:1740097633
Name:JEANIS, MICHAELA LEIGH
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:LEIGH
Last Name:JEANIS
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 1:4011 WINDMILL
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:TX
Mailing Address - Zip Code:78124-1384
Mailing Address - Country:US
Mailing Address - Phone:210-315-2124
Mailing Address - Fax:
Practice Address - Street 1:1340 E COURT ST
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-5131
Practice Address - Country:US
Practice Address - Phone:830-379-0160
Practice Address - Fax:866-589-4225
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX333501183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician