Provider Demographics
NPI:1811457567
Name:WITT, JACQUELINE GREY (MD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:GREY
Last Name:WITT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27131 FULSHEAR BEND DR
Mailing Address - Street 2:
Mailing Address - City:FULSHEAR
Mailing Address - State:TX
Mailing Address - Zip Code:77441
Mailing Address - Country:US
Mailing Address - Phone:281-612-0050
Mailing Address - Fax:
Practice Address - Street 1:27131 FULSHEAR BEND DR
Practice Address - Street 2:
Practice Address - City:FULSHEAR
Practice Address - State:TX
Practice Address - Zip Code:77441
Practice Address - Country:US
Practice Address - Phone:281-612-0050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXU3383207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program