Provider Demographics
NPI:1285048272
Name:AYOUB, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:AYOUB
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 1:1602 EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78722
Mailing Address - Country:US
Mailing Address - Phone:512-980-0590
Mailing Address - Fax:512-598-5306
Practice Address - Street 1:4301 BURNET RD STE A
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-3317
Practice Address - Country:US
Practice Address - Phone:512-980-0590
Practice Address - Fax:512-598-5306
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2020-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
TXDT8259133V00000X
TXDT82549133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDT82549OtherLD LICENSE