Healthcare Provider Details

I. General information

NPI: 1154992030
Provider Name (Legal Business Name): JANNAH PINK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4722 RIVERSTONE BLVD STE 100
MISSOURI CITY TX
77459-4723
US

IV. Provider business mailing address

4722 RIVERSTONE BLVD STE 100
MISSOURI CITY TX
77459-4723
US

V. Phone/Fax

Practice location:
  • Phone: 346-368-4412
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-172762
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: