Provider Demographics
NPI:1063787026
Name:REYNA-STOVALL, JACQUELYN PHYLLIS (RN, DNP, CNE, FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:PHYLLIS
Last Name:REYNA-STOVALL
Suffix:
Gender:F
Credentials:RN, DNP, CNE, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 OAKWELL CT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78218-3019
Mailing Address - Country:US
Mailing Address - Phone:210-829-5180
Mailing Address - Fax:
Practice Address - Street 1:3320 OAKWELL CT
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78218-3019
Practice Address - Country:US
Practice Address - Phone:210-829-5180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-09
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX672302363LF0000X
TXAP121531363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP121531OtherTEXAS LICENSE
TX3043374-01Medicaid
12363634OtherCAQH
TX3043374-02Medicaid
TX3043374-01Medicaid