Provider Demographics
NPI:1508473794
Name:JEFFREY, MARLO (AGACNP)
Entity Type:Individual
Prefix:
First Name:MARLO
Middle Name:
Last Name:JEFFREY
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6857 YOUNGER DR
Mailing Address - Street 2:
Mailing Address - City:THE COLONY
Mailing Address - State:TX
Mailing Address - Zip Code:75056-3519
Mailing Address - Country:US
Mailing Address - Phone:972-310-3362
Mailing Address - Fax:
Practice Address - Street 1:1441 N BECKLEY AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203-1201
Practice Address - Country:US
Practice Address - Phone:214-947-8181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1012021363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care