Provider Demographics
NPI:1124228622
Name:PUNNOOSE, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PUNNOOSE
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 1:3125 W FULLERTON AVE
Mailing Address - Street 2:APT 517
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-6950
Mailing Address - Country:US
Mailing Address - Phone:281-781-3230
Mailing Address - Fax:
Practice Address - Street 1:120 E HARRIS AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-5904
Practice Address - Country:US
Practice Address - Phone:325-481-8417
Practice Address - Fax:325-657-8377
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXN7741207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program