Basic Information
| Provider Information | |||||||||
| NPI: | 1679791024 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRACKEEN | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 650426 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752650426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727155000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13601 PRESTON RD | ||||||||
| Address2: | STE 1000W | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752404911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727155000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 10/03/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | OT011988 | PA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | N5584 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 213043702 | 05 | TX | MEDICAID | 213043704 | 05 | TX | MEDICAID | 213043705 | 05 | TX | MEDICAID | P00857444 | 01 | TX | RAILROAD | OTHER | 8CJ677 | 01 | BCBS | OTHER | 213043701 | 05 | TX | MEDICAID | 213043703 | 05 | TX | MEDICAID |