Basic Information
| Provider Information | |||||||||
| NPI: | 1023216793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VALDIVIESO | ||||||||
| FirstName: | JEANETTE | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUBINSTEIN | ||||||||
| OtherFirstName: | JEANETTE | ||||||||
| OtherMiddleName: | B | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8441 STATE HWY 47 | ||||||||
| Address2: | STE 3115 | ||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9794369703 | ||||||||
| FaxNumber: | 9794360072 | ||||||||
| Practice Location | |||||||||
| Address1: | 6500 ROOKIN ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133517350 | ||||||||
| FaxNumber: | 7135234897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2007 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | M7717 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No ID Information.