Provider Demographics
NPI:1407093735
Name:MUKHERJEE, JEANIECE P (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:JEANIECE
Middle Name:P
Last Name:MUKHERJEE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 162835
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-2835
Mailing Address - Country:US
Mailing Address - Phone:817-334-0530
Mailing Address - Fax:817-334-0235
Practice Address - Street 1:1000 LIPSCOMB ST STE 110
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3181
Practice Address - Country:US
Practice Address - Phone:817-348-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-08
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX678919367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00N47FOtherMEDICARE GROUP NUMBER
TX199310708Medicaid
TX199310702Medicaid
TX140442853OtherCSHCN GROUP NUMBER
TX199310703OtherCSHCN
TX137345809OtherMEDICAID GROUP NUMBER
TX00N47FOtherMEDICARE GROUP NUMBER
TX137345809OtherMEDICAID GROUP NUMBER