Healthcare Provider Details

I. General information

NPI: 1679885644
Provider Name (Legal Business Name): SELINA A JEANISE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2010
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 S SAM HOUSTON BLVD
HOUSTON MO
65483-2046
US

IV. Provider business mailing address

12496 BELL RD
ROBY MO
65557-8705
US

V. Phone/Fax

Practice location:
  • Phone: 417-967-5435
  • Fax:
Mailing address:
  • Phone: 936-676-9575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberS7075
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0102203214
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2015040163
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: