Provider Demographics
NPI:1720721590
Name:LICON, JENNIFER (FNP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LICON
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 1:2501 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-1531
Mailing Address - Country:US
Mailing Address - Phone:806-355-8900
Mailing Address - Fax:806-355-2453
Practice Address - Street 1:2701 S GEORGIA ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-1979
Practice Address - Country:US
Practice Address - Phone:806-350-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP1071121363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily