Healthcare Provider Details

I. General information

NPI: 1093168049
Provider Name (Legal Business Name): CHILDREN'S CLINIC OF JASPER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2016
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 DICKERSON DR
JASPER TX
75951-5111
US

IV. Provider business mailing address

PO BOX 150638
LUFKIN TX
75915-0638
US

V. Phone/Fax

Practice location:
  • Phone: 936-634-2214
  • Fax: 936-639-9660
Mailing address:
  • Phone: 936-634-2214
  • Fax: 936-639-9660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberH4321
License Number StateTX

VIII. Authorized Official

Name: CHERE CROCKER
Title or Position: OFFICE MANAGER
Credential:
Phone: 936-634-2214