MEDICARE: JACQUELINE MANSARAM

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1912570219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE MANSARAM

Provider Business Mailing Address
First Line	:	4119 AMERSHAM WAY
Second Line	:
City	:	SUGAR LAND
State	:	TX
Zip	:	77479-2944
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10830 CRAIGHEAD DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77025-5804
Country	:	US
Telephone Number	:	713-474-6598
Fax Number	:

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

Provider Enumeration Date	:	07/23/2021
Last Update Date	:	07/23/2021

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Directions to “ JACQUELINE MANSARAM ” Practice Location

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