Provider Demographics
NPI:1154502813
Name:STORM, JENNIFER ANN (PAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:STORM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:2855 PRESTON RD
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-9438
Mailing Address - Country:US
Mailing Address - Phone:469-495-9118
Mailing Address - Fax:
Practice Address - Street 1:2855 PRESTON RD
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-9438
Practice Address - Country:US
Practice Address - Phone:469-495-9118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002701A363A00000X
IL085003216363A00000X
MO2007030799363A00000X
TXPA12826363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00657546OtherRR MEDICARE
MOP00657546OtherRR MEDICARE
MO145740001Medicare PIN