MEDICARE: JACALYN N. JOHNSON-ALVIZA MS, PA-C

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	363A00000X	Physician Assistant	PA05001	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA05001	OTHER	TX	PA LICENSE

General Provider Information

NPI Number	:	1609944297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACALYN N. JOHNSON-ALVIZA MS, PA-C

Provider Business Mailing Address
First Line	:	1220 HOLCOMBE BLVD
Second Line	:	UNIT 1258
City	:	HOUSTON
State	:	TX
Zip	:	77030-4004
Country	:	US
Telephone Number	:	713-563-8500
Fax Number	:	713-563-8501

Provider Business Practice Location Address
First Line	:	1220 HOLCOMBE BLVD
Second Line	:	UNIT 1258
City	:	HOUSTON
State	:	TX
Zip	:	77030-4004
Country	:	US
Telephone Number	:	713-563-8500
Fax Number	:	713-563-8501

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

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	07/26/2010

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