Provider Demographics
NPI:1952332868
Name:PETTIBONE, JENNIFER L (DC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:PETTIBONE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5720 LYNDON B JOHNSON FWY
Mailing Address - Street 2:SUITE 150
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-6328
Mailing Address - Country:US
Mailing Address - Phone:972-661-2378
Mailing Address - Fax:972-233-7030
Practice Address - Street 1:5720 LYNDON B JOHNSON FWY
Practice Address - Street 2:SUITE 150
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6328
Practice Address - Country:US
Practice Address - Phone:972-661-2378
Practice Address - Fax:972-233-7030
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5935111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU49851Medicare UPIN
TX612221Medicare ID - Type Unspecified