MEDICARE: DR. JAYNE M RAQUEPAW PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TE1100X	Exercise & Sports Psychologist	24154	TX
2	103TC0700X	Clinical Psychologist	24154	TX
3	103TC1900X	Counseling Psychologist	24154	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306068051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAYNE M RAQUEPAW PHD

Provider Business Mailing Address
First Line	:	3400 BISSONNET ST
Second Line	:	STE 280
City	:	HOUSTON
State	:	TX
Zip	:	77005-2192
Country	:	US
Telephone Number	:	713-909-4841
Fax Number	:

Provider Business Practice Location Address
First Line	:	3400 BISSONNET ST
Second Line	:	STE 280
City	:	HOUSTON
State	:	TX
Zip	:	77005-2192
Country	:	US
Telephone Number	:	713-909-4841
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	08/27/2022

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