Basic Information
| Provider Information | |||||||||
| NPI: | 1508473794 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEFFREY | ||||||||
| FirstName: | MARLO | ||||||||
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| Credential: | AGACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6857 YOUNGER DR | ||||||||
| Address2: | |||||||||
| City: | THE COLONY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750563519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723103362 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1441 N BECKLEY AVE | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752031201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149478181 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2020 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 1012021 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.