Provider Demographics
NPI:1063798452
Name:PHENOMENAL OUTREACH CENTER
Entity type:Organization
Organization Name:PHENOMENAL OUTREACH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROGRAM MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:HELEN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-877-2207
Mailing Address - Street 1:6102 LAURA KOPPE RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77016-5440
Mailing Address - Country:US
Mailing Address - Phone:832-877-2207
Mailing Address - Fax:
Practice Address - Street 1:6102 LAURA KOPPE RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77016-5440
Practice Address - Country:US
Practice Address - Phone:832-877-2207
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-29
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization