Provider Demographics
NPI:1699912881
Name:GANACIAS, JACLYN LEE ANN (MD)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:LEE ANN
Last Name:GANACIAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 E BELT LINE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-2422
Mailing Address - Country:US
Mailing Address - Phone:972-291-7863
Mailing Address - Fax:972-291-0942
Practice Address - Street 1:950 E BELT LINE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-2422
Practice Address - Country:US
Practice Address - Phone:972-291-7863
Practice Address - Fax:972-291-0942
Is Sole Proprietor?:No
Enumeration Date:2009-01-09
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3041207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX204025501Medicaid
TX8L16028Medicare PIN