Provider Demographics
NPI:1245600154
Name:SORRELLE-FERGUSON, JENNIFER (NNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SORRELLE-FERGUSON
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:SORRELLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:929 GESSNER
Mailing Address - Street 2:MEMORIAL HERMAN TOWER 4TH FLOOR NEONATOLOGY
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:929 GESSNER RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024
Practice Address - Country:US
Practice Address - Phone:602-476-8961
Practice Address - Fax:623-643-9236
Is Sole Proprietor?:No
Enumeration Date:2015-10-05
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP163WN0002X
TXAP125598363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1245600154Medicaid