Provider Demographics
NPI:1417657859
Name:QU, JIAYI
Entity type:Individual
Prefix:
First Name:JIAYI
Middle Name:
Last Name:QU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:
Other - Last Name:QU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2402 S JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455-5959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2402 S JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-5959
Practice Address - Country:US
Practice Address - Phone:903-573-7195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2025-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41515122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist