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NPI Code Detail

MEDICARE: JERRIE DENISE SAN LUIS RN

MEDICARE: JERRIE DENISE SAN LUIS RN
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1163WA0400XAddiction (Substance Use Disorder) Registered Nurse652119TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1652119OTHERTXNURSE LICENSE-REGISTERED NURSE

General Provider Information

NPI Number : 1013667708
Entity Type Code : Individual
Provider Name (Legal Business Name) : JERRIE DENISE SAN LUIS RN
Provider Business Mailing Address
First Line : 1110 W WILLIAM CANNON DR STE 303
Second Line :
City : AUSTIN
State : TX
Zip : 78745-3188
Country : US
Telephone Number : 512-899-2100
Fax Number : 512-899-2205
Provider Business Practice Location Address
First Line : 1110 W WILLIAM CANNON DR STE 303
Second Line :
City : AUSTIN
State : TX
Zip : 78745-3188
Country : US
Telephone Number : 512-899-2100
Fax Number : 512-899-2205
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/25/2022
Last Update Date : 03/25/2022

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Directions to “ JERRIE DENISE SAN LUIS RN” Practice Location

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