Provider Demographics
NPI:1225857063
Name:PRUITT, JACKIE LEIGH (CHW)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:LEIGH
Last Name:PRUITT
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 WESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GUN BARREL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:75156-3508
Mailing Address - Country:US
Mailing Address - Phone:903-910-7804
Mailing Address - Fax:
Practice Address - Street 1:166 WESTVIEW DR
Practice Address - Street 2:
Practice Address - City:GUN BARREL CITY
Practice Address - State:TX
Practice Address - Zip Code:75156-3508
Practice Address - Country:US
Practice Address - Phone:903-910-7804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker