Provider Demographics
NPI:1972940260
Name:PENN, JACKIE IJEOMA (NP)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:IJEOMA
Last Name:PENN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5319 NUECES LN
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-2667
Mailing Address - Country:US
Mailing Address - Phone:214-584-4103
Mailing Address - Fax:
Practice Address - Street 1:5319 NUECES LN
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-2667
Practice Address - Country:US
Practice Address - Phone:214-584-4103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-28
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX783349163W00000X
TX1056737363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse