Provider Demographics
NPI:1588641393
Name:MCCLENDON, JENNIFER A (CRNA)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:A
Last Name:MCCLENDON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 W. COLORADO BLVD.
Mailing Address - Street 2:SUITE 845
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208
Mailing Address - Country:US
Mailing Address - Phone:214-946-1133
Mailing Address - Fax:817-877-0350
Practice Address - Street 1:221 W. COLORADO BLVD.
Practice Address - Street 2:SUITE 845
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208
Practice Address - Country:US
Practice Address - Phone:214-946-1133
Practice Address - Fax:817-877-0350
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX240585367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX088706904Medicaid
TX171484201Medicaid
TX088706905Medicaid
TX088706906Medicaid
TX84562UOtherBCBS
TX171484201Medicaid
TX8D0207Medicare PIN
TX8D3606Medicare PIN
R69761Medicare UPIN