Provider Demographics
NPI:1730290990
Name:JENNINGS, NICOLE BLACKWELL (PA-C)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:BLACKWELL
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:LEA
Other - Last Name:BLACKWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-6163
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:1500 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:682-885-2500
Practice Address - Fax:682-885-2510
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04862363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L23098Medicare PIN
NC2771001Medicare PIN