Provider Demographics
NPI:1073501946
Name:RAVENSCROFT, JENNIFER LYNN (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:RAVENSCROFT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 C ST. WEST
Mailing Address - Street 2:AFPC/DPFDF
Mailing Address - City:JBSA-RANDOLPH AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78150
Mailing Address - Country:US
Mailing Address - Phone:210-565-2182
Mailing Address - Fax:
Practice Address - Street 1:359 MEDICAL GROUP
Practice Address - Street 2:221 THIRD ST. WEST BLDG 1040
Practice Address - City:JBSA-RANDOLPH
Practice Address - State:TX
Practice Address - Zip Code:78150
Practice Address - Country:US
Practice Address - Phone:210-652-8544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1776207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine