Healthcare Provider Details

I. General information

NPI: 1003981663
Provider Name (Legal Business Name): JACKIE E WANEBO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 FANNIN ST SUITE #3300
HOUSTON TX
77054-2934
US

IV. Provider business mailing address

7900 FANNIN ST SUITE #3300
HOUSTON TX
77054-2934
US

V. Phone/Fax

Practice location:
  • Phone: 713-630-0660
  • Fax: 713-796-2555
Mailing address:
  • Phone: 713-630-0660
  • Fax: 713-796-2555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberJ9428
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: