Healthcare Provider Details

I. General information

NPI: 1891042925
Provider Name (Legal Business Name): JACKLYN RENEE SCHALLENBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. JACKLYN RENEE OWINGS

II. Dates (important events)

Enumeration Date: 08/08/2012
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 SW 36TH ST
SAN ANTONIO TX
78237-3360
US

IV. Provider business mailing address

PO BOX 87
SAN ANTONIO TX
78291-0087
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-5100
  • Fax: 210-358-5157
Mailing address:
  • Phone: 210-358-9174
  • Fax: 210-358-5753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA07952
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: