Provider Demographics
NPI:1912261140
Name:BERRY, JENNY REPLOGLE (APN)
Entity type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:REPLOGLE
Last Name:BERRY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:NICOLE
Other - Last Name:REPLOGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4439
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4439
Mailing Address - Country:US
Mailing Address - Phone:713-792-2991
Mailing Address - Fax:
Practice Address - Street 1:1515 HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2009
Practice Address - Country:US
Practice Address - Phone:713-792-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-03
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012004406363LA2200X
TX1953363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX880N26OtherBCBS
TX308238001Medicaid
TX880N26OtherBCBS