Provider Demographics
NPI:1437783057
Name:MANTILLA, JENNIFER MAE (BSN, RN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MAE
Last Name:MANTILLA
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MAE
Other - Last Name:MANTILLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:JENNIFER PIERSON
Mailing Address - Street 1:3053 SAN MARCOS DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-4830
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3053 SAN MARCOS DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-4830
Practice Address - Country:US
Practice Address - Phone:817-637-8019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX981475163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse