Provider Demographics
NPI:1629313564
Name:ZIELKE, JENNIFER GRACE (CRNA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:GRACE
Last Name:ZIELKE
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:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:972-715-9976
Practice Address - Street 1:1307 8TH AVE STE 506
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4142
Practice Address - Country:US
Practice Address - Phone:817-332-6092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-04
Last Update Date:2022-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX738696367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX312727602Medicaid
TX8791UGOtherBCBS
TXP01446813OtherRR
TX8791UGOtherBCBS