Provider Demographics
NPI:1003284902
Name:LIM, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 MILLER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76105-5049
Mailing Address - Country:US
Mailing Address - Phone:817-536-4593
Mailing Address - Fax:817-536-0140
Practice Address - Street 1:3100 MILLER AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76105-5049
Practice Address - Country:US
Practice Address - Phone:817-536-4593
Practice Address - Fax:817-536-0140
Is Sole Proprietor?:No
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX57337183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX57337OtherTEXAS PHARMACIST LICENSE