Provider Demographics
NPI: | 1376920132 |
---|---|
Name: | TEJADA OLLER, JENNIFER (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | JENNIFER |
Middle Name: | |
Last Name: | TEJADA OLLER |
Suffix: | |
Gender: | F |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | JENNIFER |
Other - Middle Name: | |
Other - Last Name: | TEJADA |
Other - Suffix: | |
Other - Last Name Type: | Other Name |
Other - Credentials: | MD |
Mailing Address - Street 1: | 2900 E 29TH ST STE 100 |
Mailing Address - Street 2: | |
Mailing Address - City: | BRYAN |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 77802-2623 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 979-776-0884 |
Mailing Address - Fax: | 877-601-5854 |
Practice Address - Street 1: | 2900 E 29TH ST |
Practice Address - Street 2: | |
Practice Address - City: | BRYAN |
Practice Address - State: | TX |
Practice Address - Zip Code: | 77802-2622 |
Practice Address - Country: | US |
Practice Address - Phone: | 979-776-8440 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2015-04-30 |
Last Update Date: | 2022-10-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
390200000X | ||
TX | 47152 | 2084P0800X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 1F2393 | Other | MEDICARE |
TX | 414421401 | Medicaid |