Provider Demographics
NPI:1629213756
Name:KAVANAUGH, JENNA L (PA)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:L
Last Name:KAVANAUGH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 SETON CENTER PKWY
Mailing Address - Street 2:SUITE 215
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5290
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 W 38TH ST STE 102
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1010
Practice Address - Country:US
Practice Address - Phone:512-454-4561
Practice Address - Fax:512-406-7330
Is Sole Proprietor?:No
Enumeration Date:2008-12-03
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05983363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX200565403Medicaid
TX200565402Medicaid
TX564906YKXYMedicare PIN
TX200565402Medicaid
TXTXB121097Medicare PIN