1477620615 NPI number — JAKPA HEALTHCARE INC

Table of content: (NPI 1477620615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477620615 NPI number — JAKPA HEALTHCARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAKPA HEALTHCARE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477620615
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
285 W SOUTHWEST PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEWISVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75067-7770
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-222-3100
Provider Business Mailing Address Fax Number:
214-222-3103

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 MISTY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75067-6253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-222-3100
Provider Business Practice Location Address Fax Number:
214-222-3103
Provider Enumeration Date:
11/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
AGBONTAEN
Authorized Official First Name:
OFIORITSE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTATOR
Authorized Official Telephone Number:
214-222-3100

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X , with the licence number: 008874 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3747P1801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001013165 . This is a "MDCP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 001013167 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001013166 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".