Provider Demographics
NPI:1417293960
Name:DAVISON, JENNA LOGAN (PA)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:LOGAN
Last Name:DAVISON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:LOGAN
Other - Last Name:BREWER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7801 OAKMONT BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4204
Mailing Address - Country:US
Mailing Address - Phone:817-263-0007
Mailing Address - Fax:817-263-1118
Practice Address - Street 1:7801 OAKMONT BLVD
Practice Address - Street 2:STE 101
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4204
Practice Address - Country:US
Practice Address - Phone:817-263-0007
Practice Address - Fax:817-263-1118
Is Sole Proprietor?:No
Enumeration Date:2013-01-02
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08103363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant