1972068328 NPI number — MISS JORDAN KREUSCH PTA

Table of content: MISS JORDAN KREUSCH PTA (NPI 1972068328)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972068328 NPI number — MISS JORDAN KREUSCH PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KREUSCH
Provider First Name:
JORDAN
Provider Middle Name:
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PTA
Provider Gender Code:
F

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:
1972068328
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
225 TENNISON RD APT 4208
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT PLEASANT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75455-9358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-498-7114
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 N JEFFERSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT PLEASANT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75455-2338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-577-6000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/08/2019

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: 225200000X , with the licence number:  2131697 , 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)