Healthcare Provider Details

I. General information

NPI: 1215141387
Provider Name (Legal Business Name): JACKIE K WURTZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11515 FM 1960 RD STE C
HUFFMAN TX
77336-4431
US

IV. Provider business mailing address

PO BOX 1365
HUFFMAN TX
77336-1365
US

V. Phone/Fax

Practice location:
  • Phone: 281-324-1550
  • Fax: 281-324-1555
Mailing address:
  • Phone: 281-324-1550
  • Fax: 281-324-1555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number564809
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: