Provider Demographics
NPI:1083229611
Name:PREMO, JENNIFER URBANI (EDDIAGNOSTICIANMED)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:URBANI
Last Name:PREMO
Suffix:
Gender:F
Credentials:EDDIAGNOSTICIANMED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4125 BEECHWOOD LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75220-1905
Mailing Address - Country:US
Mailing Address - Phone:214-532-6726
Mailing Address - Fax:
Practice Address - Street 1:4125 BEECHWOOD LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75220-1905
Practice Address - Country:US
Practice Address - Phone:214-532-6726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251B00000X, 251S00000X, 261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health