Basic Information
| Provider Information | |||||||||
| NPI: | 1104301852 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ETHRIDGE | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2925 BRIARPARK DR STE 575 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770423776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8326262842 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1150 N LOOP 1604 W STE 150 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782484505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817838162 | ||||||||
| FaxNumber: | 7134397995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2018 | ||||||||
| LastUpdateDate: | 06/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | TEMPORARY | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA12348 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.