Provider Demographics
NPI:1205903424
Name:ANDERSON, JACQUELINE DENISE (SURGICAL ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:DENISE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:SURGICAL ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 ACR 3593
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75803
Mailing Address - Country:US
Mailing Address - Phone:903-729-1518
Mailing Address - Fax:903-389-4237
Practice Address - Street 1:640 ACR 3593
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75803
Practice Address - Country:US
Practice Address - Phone:903-729-1518
Practice Address - Fax:903-389-4237
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00028171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0067JROtherBCBS ID