Provider Demographics
NPI:1073530689
Name:MOTLEY, JENNIFER L (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:MOTLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 ELM ST
Mailing Address - Street 2:
Mailing Address - City:RAWLINS
Mailing Address - State:WY
Mailing Address - Zip Code:82301-5108
Mailing Address - Country:US
Mailing Address - Phone:307-324-2221
Mailing Address - Fax:
Practice Address - Street 1:4760 BARWICK DR STE C
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132
Practice Address - Country:US
Practice Address - Phone:817-346-9533
Practice Address - Fax:817-346-9788
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYTL6447207V00000X
TXL7491207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX163673001Medicaid
P00247387OtherRAILROAD MEDICARE
TX163673001Medicaid