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General NPI Number Information
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NPI Number | 1730306572
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Entity Type | Individual
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Provider Name | JACLYN JO ANDREW
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Gender | Female
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Dates
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Enumeration Date | 04/20/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 4600 TAFT BLVD
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City | WICHITA FALLS
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State | TX
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Zip | 76308-4935
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Country | US
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Telephone | 940-691-1710
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Fax | 940-691-2193
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Provider Business Mailing Address
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Address Line | 5238 SUNNYBROOK LN
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City | WICHITA FALLS
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State | TX
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Zip | 76310-3497
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Country | US
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Telephone | 940-642-2193
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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 | 174400000X
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Taxonomy Name | Specialist
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License Number | 111348
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License Number State | TX
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