=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841996576
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACKQULAINE DEANN SPENCER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2023
-----------------------------------------------------
Last Update Date | 02/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4901 MAPLE SHADE AVE
-----------------------------------------------------
City | SACHSE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75048-4682
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-997-5718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2100 14TH ST STE 107 #2047
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-997-5718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247ZC0005X
-----------------------------------------------------
Taxonomy Name | Clinical Laboratory Director (Non-physician)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------