MEDICARE: JSJ WELLNESS DIAGNOSTIC LABORATORY

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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1952855256
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JSJ WELLNESS DIAGNOSTIC LABORATORY

Provider Business Mailing Address
First Line	:	7707 FANNIN ST STE 205
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-1968
Country	:	US
Telephone Number	:	832-786-7009
Fax Number	:	832-831-1579

Provider Business Practice Location Address
First Line	:	7707 FANNIN ST STE 205
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-1968
Country	:	US
Telephone Number	:	832-786-7009
Fax Number	:	832-831-1579

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	MR. SCOTT STOECKEL
Credential	:
Telephone Number	:	832-786-7009

Provider Enumeration Date	:	08/04/2016
Last Update Date	:	08/04/2016

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