Healthcare Provider Details

I. General information

NPI: 1215194303
Provider Name (Legal Business Name): JASPER FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2008
Last Update Date: 11/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 W GIBSON ST
JASPER TX
75951-4936
US

IV. Provider business mailing address

150 W GIBSON ST
JASPER TX
75951-4936
US

V. Phone/Fax

Practice location:
  • Phone: 409-384-1700
  • Fax: 409-384-1701
Mailing address:
  • Phone: 409-384-1700
  • Fax: 409-384-1701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA03271
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1163
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberK4930
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number676518
License Number StateTX

VIII. Authorized Official

Name: ELIZABETH ANN BENTON
Title or Position: SOLE OWNER
Credential:
Phone: 281-220-7549