Provider Demographics
NPI:1194118877
Name:JAKUBOWSKI, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:JAKUBOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 E BELT LINE RD
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-9606
Mailing Address - Country:US
Mailing Address - Phone:972-393-8687
Mailing Address - Fax:972-393-4975
Practice Address - Street 1:1705 E BELT LINE RD STE D
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-9606
Practice Address - Country:US
Practice Address - Phone:972-393-8687
Practice Address - Fax:972-393-8687
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP145528363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX424394101Medicaid
TXAP145528OtherLICENSE NUMBER