Provider Demographics
NPI:1912411562
Name:ANDERSON, JENNA LEIGH (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JENNA
Middle Name:LEIGH
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1900 MISTLETOE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4049
Mailing Address - Country:US
Mailing Address - Phone:239-699-4741
Mailing Address - Fax:
Practice Address - Street 1:1900 MISTLETOE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4049
Practice Address - Country:US
Practice Address - Phone:817-878-5333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-17
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant