Provider Demographics
NPI:1386821270
Name:DONNELLY STRAACH, JENNIFER LAUREN (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LAUREN
Last Name:DONNELLY STRAACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 E SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6422
Mailing Address - Country:US
Mailing Address - Phone:817-442-9300
Mailing Address - Fax:
Practice Address - Street 1:1545 E SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6422
Practice Address - Country:US
Practice Address - Phone:817-442-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2774208100000X
TXN5658208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation