Provider Demographics
NPI:1285868612
Name:CHILES, JENNIFER MIRA (DO)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MIRA
Last Name:CHILES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:MIRA
Other - Last Name:OH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:36065 SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544-5060
Mailing Address - Country:US
Mailing Address - Phone:254-288-8109
Mailing Address - Fax:518-875-8564
Practice Address - Street 1:36065 SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5060
Practice Address - Country:US
Practice Address - Phone:254-288-8109
Practice Address - Fax:518-875-8564
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-13
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXP5440207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program