Healthcare Provider Details

I. General information

NPI: 1467732438
Provider Name (Legal Business Name): JBCM-1
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 08/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9402 MESA DR
HOUSTON TX
77028-1201
US

IV. Provider business mailing address

9402 MESA DR
HOUSTON TX
77028-1201
US

V. Phone/Fax

Practice location:
  • Phone: 713-633-1626
  • Fax: 713-635-6253
Mailing address:
  • Phone: 713-633-1626
  • Fax: 713-635-6253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number774906
License Number StateTX

VIII. Authorized Official

Name: JACK T BARNETT
Title or Position: SOLE MBR
Credential: FNP
Phone: 713-633-1626