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General NPI Number Information
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NPI Number | 1134682347
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Entity Type | Individual
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Provider Name | LICIAMMA JACOB
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Gender | Female
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Dates
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Enumeration Date | 04/13/2019
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Last Update Date | 04/13/2019
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Provider Practice Location Address
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Address Line | 4600 E SAM HOUSTON PKWY S
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City | PASADENA
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State | TX
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Zip | 77505-3948
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Country | US
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Telephone | 713-948-7388
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Fax |
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Provider Business Mailing Address
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Address Line | 2708 RAVEN RIDGE DR
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City | PEARLAND
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State | TX
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Zip | 77584-3442
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Country | US
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Telephone | 713-436-1818
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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 | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | AP138632
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License Number State | TX
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