Basic Information
| Provider Information | |||||||||
| NPI: | 1295202604 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIFFIN | ||||||||
| FirstName: | JACAIL | ||||||||
| MiddleName: | SHAWUAN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 130549 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757130549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035793931 | ||||||||
| FaxNumber: | 9035095835 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 OLYMPIC PLAZA CIR | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757011950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035963587 | ||||||||
| FaxNumber: | 9035942647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2018 | ||||||||
| LastUpdateDate: | 10/24/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP139288 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.