Active NPI
Jackie Phan
- Pharmacist
- Beaumont, TX
National Provider Identifier
1649861022
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- 67905
- Practice address
- 3605 College St
Beaumont, TX 77701-4617 - Phone
- (409) 832-7374
- NPI assigned
- Jan 28, 2021
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 67905 | TX | Primary |
Addresses
Primary practice location
3605 College St
Beaumont, TX 77701-4617
Mailing address
20602 Spring Mission LN
Spring, TX 77388-5366
Phone (281) 928-6101
Other practice location 1
20602 Spring Mission Ln
Spring, TX 77388-5366
Phone (281) 928-6101
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 67905 | TX | MD | Mental Health Counselor |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Walgreen Co | Past | Accepting new patients | |
| Walgreen Co | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1611792000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1611792000000",
"number": "1649861022",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "20602 SPRING MISSION LN",
"city": "SPRING",
"state": "TX",
"postal_code": "773885366",
"telephone_number": "281-928-6101"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3605 COLLEGE ST",
"city": "BEAUMONT",
"state": "TX",
"postal_code": "777014617",
"telephone_number": "409-832-7374"
}
],
"practiceLocations": [
{
"address_1": "20602 Spring Mission Ln",
"address_purpose": "LOCATION",
"city": "Spring",
"state": "TX",
"postal_code": "773885366",
"country_code": "US",
"telephone_number": "281-928-6101",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "PHAN",
"first_name": "JACKIE",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2021-01-28",
"last_updated": "2021-01-28",
"certification_date": "2021-01-26",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "TX",
"license": "67905",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Beaumont, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 28, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.