Provider Demographics
NPI:1891724282
Name:LUNCEFORD, JENNIFER A (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:LUNCEFORD
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:PO BOX 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:2026 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-5822
Practice Address - Country:US
Practice Address - Phone:903-586-5678
Practice Address - Fax:903-541-4679
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02328363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7057548OtherAETNA
TX8192NPOtherBCBS
TXP01492565OtherRAIL ROAD
TX8821NFOtherBCBS
TX75-1976930-005OtherTRICARE
TX187881104Medicaid
TX7057548OtherAETNA
TX187881104Medicaid
TX399548YS6VMedicare PIN