Basic Information
| Provider Information | |||||||||
| NPI: | 1588009955 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TILLER | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 845347 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752845347 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5323 HARRY HINES BLVD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753905812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144567000 | ||||||||
| FaxNumber: | 2144568132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2013 | ||||||||
| LastUpdateDate: | 11/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0204X | 2016-00578 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 2080P0204X | S2182 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
No ID Information.