Provider Demographics
NPI:1659660348
Name:KIDD, JENNIFER BENTLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:BENTLEY
Last Name:KIDD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:RYAN
Other - Last Name:BENTLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 328
Mailing Address - Street 2:
Mailing Address - City:PORT ARANSAS
Mailing Address - State:TX
Mailing Address - Zip Code:78373-0328
Mailing Address - Country:US
Mailing Address - Phone:210-872-1863
Mailing Address - Fax:
Practice Address - Street 1:401 S 12TH ST
Practice Address - Street 2:
Practice Address - City:PORT ARANSAS
Practice Address - State:TX
Practice Address - Zip Code:78373-5328
Practice Address - Country:US
Practice Address - Phone:210-872-1863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ55422083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine