Provider Demographics
NPI:1679791024
Name:BRACKEEN, JENNIFER (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BRACKEEN
Suffix:
Gender:F
Credentials:DO
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 650426
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0426
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:
Practice Address - Street 1:13601 PRESTON RD
Practice Address - Street 2:STE 1000W
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-4911
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT011988207L00000X
TXN5584207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX213043702Medicaid
TX213043704Medicaid
TX213043705Medicaid
TXP00857444OtherRAILROAD
8CJ677OtherBCBS
TX213043701Medicaid
TX213043703Medicaid
TX213043705Medicaid
TXTXB110444Medicare PIN
TXTXB104896Medicare PIN