Provider Demographics
NPI:1831520899
Name:REBOLLEDO, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:REBOLLEDO
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 1:605 PECOS DR
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76039-7526
Mailing Address - Country:US
Mailing Address - Phone:817-721-7343
Mailing Address - Fax:
Practice Address - Street 1:2609 SAGEBRUSH DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-2733
Practice Address - Country:US
Practice Address - Phone:972-539-4875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08637363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical