Provider Demographics
NPI:1396978243
Name:DEGROOT, JAYMA LEE (FNP-C)
Entity type:Individual
Prefix:
First Name:JAYMA
Middle Name:LEE
Last Name:DEGROOT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 ROCKETT LN
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75154-7812
Mailing Address - Country:US
Mailing Address - Phone:214-725-8173
Mailing Address - Fax:
Practice Address - Street 1:3100 MCKINNON ST
Practice Address - Street 2:SUITE 400
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-1044
Practice Address - Country:US
Practice Address - Phone:214-754-8700
Practice Address - Fax:214-239-3769
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-26
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX628711363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX206791007Medicaid
TX206791007Medicaid