Provider Demographics
NPI:1104420298
Name:MATHIS, JACQUELINE (MSN, MPH)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MATHIS
Suffix:
Gender:F
Credentials:MSN, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7110 SAGEBRANCH CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-6489
Mailing Address - Country:US
Mailing Address - Phone:713-878-1043
Mailing Address - Fax:
Practice Address - Street 1:7110 SAGEBRANCH CT
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-6489
Practice Address - Country:US
Practice Address - Phone:713-878-1043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1014402363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner