1679791024 NPI number — JENNIFER BRACKEEN D.O.

Table of content: JENNIFER BRACKEEN D.O. (NPI 1679791024)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679791024 NPI number — JENNIFER BRACKEEN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRACKEEN
Provider First Name:
JENNIFER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679791024
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 650426
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75265-0426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-715-5000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13601 PRESTON RD
Provider Second Line Business Practice Location Address:
STE 1000W
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75240-4911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-715-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  OT011988 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: N5584 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 213043702 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 213043704 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 213043705 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00857444 . This is a "RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8CJ677 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 213043701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 213043703 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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