Provider Demographics
NPI:1982614715
Name:JENNIFER WEATHERLY, D.O. P.A
Entity type:Organization
Organization Name:JENNIFER WEATHERLY, D.O. P.A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ANDREA
Authorized Official - Last Name:WEATHERLY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-274-5200
Mailing Address - Street 1:3250 W PLEASANT RUN RD STE 160
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:TX
Mailing Address - Zip Code:75146-1071
Mailing Address - Country:US
Mailing Address - Phone:972-274-5200
Mailing Address - Fax:972-274-5217
Practice Address - Street 1:3250 W PLEASANT RUN RD STE 160
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:TX
Practice Address - Zip Code:75146-1071
Practice Address - Country:US
Practice Address - Phone:972-274-5200
Practice Address - Fax:972-274-5217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0076KTOtherBCBS
H73802Medicare UPIN
TX00332WMedicare PIN
TX00332WMedicare PIN