Provider Demographics
NPI:1386093672
Name:MATHEW, JENNIE
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:MATHEW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N PRESTON RD STE 20
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-8891
Mailing Address - Country:US
Mailing Address - Phone:469-296-8030
Mailing Address - Fax:888-851-4582
Practice Address - Street 1:1000 N PRESTON RD STE 20
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-8891
Practice Address - Country:US
Practice Address - Phone:469-296-8030
Practice Address - Fax:888-851-4582
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2025-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34728208000000X
PAMT211153208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics