Basic Information
| Provider Information | |||||||||
| NPI: | 1093178360 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARUSSA | ||||||||
| FirstName: | JACQUELYN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 WHITE WILLOW LN | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760024645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857902260 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1650 W COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174811588 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2016 | ||||||||
| LastUpdateDate: | 08/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | S0492 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.