Provider Demographics
NPI:1972693471
Name:FOURNIER, JACQUELINE F (MD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:F
Last Name:FOURNIER
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 1:6210 E US HWY 290
Mailing Address - Street 2:STE 420 - CREDENTIALING
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1098
Mailing Address - Country:US
Mailing Address - Phone:512-338-3826
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:27760 RANCH ROAD 12
Practice Address - Street 2:BLDG 1
Practice Address - City:DRIPPING SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:78620
Practice Address - Country:US
Practice Address - Phone:512-829-9118
Practice Address - Fax:512-406-7301
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2903208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104596507Medicaid
TX104596506Medicaid
TX104596504Medicaid
TX104596505Medicaid
OK200013510AMedicaid
TX104596507Medicaid
TX8L11625Medicare PIN
TXTXB111324Medicare PIN
TX8L10973Medicare PIN
TX104596505Medicaid