Provider Demographics
NPI:1053985192
Name:URSUA, JOCELYN DERIENNE MACK
Entity type:Individual
Prefix:MISS
First Name:JOCELYN DERIENNE
Middle Name:MACK
Last Name:URSUA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOSHUA DEREK
Other - Middle Name:MACK
Other - Last Name:URSUA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6431 FANNIN ST
Mailing Address - Street 2:MSB 1.134
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1501
Mailing Address - Country:US
Mailing Address - Phone:318-210-7066
Mailing Address - Fax:
Practice Address - Street 1:6431 FANNIN STREET
Practice Address - Street 2:MSB 1.134
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:318-210-7066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program