Provider Demographics
NPI:1518594852
Name:VANDENBERG, JENNIFER (AGACNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:VANDENBERG
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 1:125 CAMOUFLAGE CIR
Mailing Address - Street 2:
Mailing Address - City:WILLOW PARK
Mailing Address - State:TX
Mailing Address - Zip Code:76008-1107
Mailing Address - Country:US
Mailing Address - Phone:817-565-8907
Mailing Address - Fax:
Practice Address - Street 1:1300 W TERRELL AVE
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2820
Practice Address - Country:US
Practice Address - Phone:817-250-4906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143770363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care