1710793146 NPI number — COURTNEY JESSICA TEAGUE PA

Table of content: COURTNEY JESSICA TEAGUE PA (NPI 1710793146)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710793146 NPI number — COURTNEY JESSICA TEAGUE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEAGUE
Provider First Name:
COURTNEY
Provider Middle Name:
JESSICA
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:
CHRISTENSEN
Provider Other First Name:
COURTNEY
Provider Other Middle Name:
JESSICA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710793146
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2434 HICKORY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ABILENE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79698-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-660-2774
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 N ROSE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OXNARD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93030-3722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-988-2500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/10/2024

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 65659 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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