Provider Demographics
NPI:1184859225
Name:VICKERS, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:VICKERS
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 1:313 E 12TH ST
Mailing Address - Street 2:STE 100
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-1954
Mailing Address - Country:US
Mailing Address - Phone:512-324-9650
Mailing Address - Fax:
Practice Address - Street 1:313 E 12TH ST
Practice Address - Street 2:STE 100
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-1954
Practice Address - Country:US
Practice Address - Phone:512-324-9650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP8626207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX337718601Medicaid
TX352126YL9XMedicare PIN
TX337718601Medicaid