Provider Demographics
NPI:1801665211
Name:ANDERSON, JACQUELYN LYNETTE
Entity type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:LYNETTE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:LYNETTE
Other - Last Name:GUERRERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12222 BLANCO RD APT 704
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-2112
Mailing Address - Country:US
Mailing Address - Phone:979-505-0203
Mailing Address - Fax:
Practice Address - Street 1:6000 WEST AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-2714
Practice Address - Country:US
Practice Address - Phone:210-341-3875
Practice Address - Fax:210-344-1887
Is Sole Proprietor?:No
Enumeration Date:2023-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX233892183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician