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General NPI Number Information
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NPI Number | 1114612041
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Entity Type | Individual
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Provider Name | JACKELINE PEREZ
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Gender | Female
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Dates
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Enumeration Date | 04/06/2023
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Last Update Date | 07/30/2025
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Provider Practice Location Address
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Address Line | 1661 W 2ND AVE
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City | CORSICANA
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State | TX
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Zip | 75110-4107
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Country | US
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Telephone | 903-872-1661
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Fax |
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Provider Business Mailing Address
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Address Line | 3909 LIVINGSTON AVE
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City | FORT WORTH
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State | TX
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Zip | 76110-6063
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Country | US
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Telephone | 817-204-7514
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 41577
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License Number State | TX
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