Healthcare Provider Details

I. General information

NPI: 1912102583
Provider Name (Legal Business Name): JACLYN TERESA MARROQUIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 SAINT DAVIDS LOOP STE 320
LEANDER TX
78641-5225
US

IV. Provider business mailing address

505 SAINT DAVIDS LOOP STE 320
LEANDER TX
78641-5225
US

V. Phone/Fax

Practice location:
  • Phone: 737-843-7533
  • Fax: 737-843-7535
Mailing address:
  • Phone: 737-843-7533
  • Fax: 737-843-7535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberBP10026814
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberN3867
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: