Provider Demographics
NPI:1902938046
Name:DO, JACQUELYN (DDS)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:DO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 BROADWAY STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581
Mailing Address - Country:US
Mailing Address - Phone:281-485-1133
Mailing Address - Fax:281-485-1166
Practice Address - Street 1:3525 BROADWAY STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581
Practice Address - Country:US
Practice Address - Phone:281-485-1133
Practice Address - Fax:281-485-1166
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0023838122300000X
CA53206122300000X
CAD532061223G0001X
TX23838122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD53206OtherDENTI-CAL PROVIDER NUMBER