Provider Demographics
NPI:1578311106
Name:JEAN, ELSY (CRANIAL PROTHESIS)
Entity type:Individual
Prefix:
First Name:ELSY
Middle Name:
Last Name:JEAN
Suffix:
Gender:F
Credentials:CRANIAL PROTHESIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 S WW WHITE RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78220-1517
Mailing Address - Country:US
Mailing Address - Phone:772-267-2087
Mailing Address - Fax:
Practice Address - Street 1:6107 LAKEFRONT ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78222-1523
Practice Address - Country:US
Practice Address - Phone:772-267-2087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8HOQM7Y1RI335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier