1710209903 NPI number — JACKLYN MARIE ELMER PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710209903 NPI number — JACKLYN MARIE ELMER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELMER
Provider First Name:
JACKLYN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ARPE
Provider Other First Name:
JACKLYN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710209903
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4324 THAMES CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLOWER MOUND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75028-1778
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-967-4829
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4324 THAMES CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLOWER MOUND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75028-1778
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-967-4829
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/16/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA06585 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 321033801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 835N10 . This is a "BC/BS TX - EFFECT 02/01/2011" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P00935316 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: PA06585 . This is a "TX MEDICAL LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 816N94 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: TXB121235 . This is a "MEDICARE PART B - EFFECT 02/01/2011" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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