Provider Demographics
NPI:1447708128
Name:CLEARLAKE KIDS PSYCHIATRY
Entity type:Organization
Organization Name:CLEARLAKE KIDS PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:903-918-3294
Mailing Address - Street 1:17226 MERCURY DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-2792
Mailing Address - Country:US
Mailing Address - Phone:281-975-0600
Mailing Address - Fax:
Practice Address - Street 1:17226 MERCURY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-2792
Practice Address - Country:US
Practice Address - Phone:281-975-0600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-12
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00473363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty