Provider Demographics
NPI:1407295785
Name:SEALE, JENNIFER MARGARITA (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARGARITA
Last Name:SEALE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARGARITA
Other - Last Name:RONCALLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1600 PROVIDENCE DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76707-2261
Mailing Address - Country:US
Mailing Address - Phone:254-313-4200
Mailing Address - Fax:254-313-4326
Practice Address - Street 1:1600 PROVIDENCE DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76707-2261
Practice Address - Country:US
Practice Address - Phone:254-313-4200
Practice Address - Fax:254-313-4531
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10047966207Q00000X
TXQ6696207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine