MEDICARE: JENNIFER L PETTIBONE D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	5935	TX

General Provider Information

NPI Number	:	1952332868
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER L PETTIBONE D.C.

Provider Business Mailing Address
First Line	:	5720 LYNDON B JOHNSON FWY
Second Line	:	SUITE 150
City	:	DALLAS
State	:	TX
Zip	:	75240-6328
Country	:	US
Telephone Number	:	972-661-2378
Fax Number	:	972-233-7030

Provider Business Practice Location Address
First Line	:	5720 LYNDON B JOHNSON FWY
Second Line	:	SUITE 150
City	:	DALLAS
State	:	TX
Zip	:	75240-6328
Country	:	US
Telephone Number	:	972-661-2378
Fax Number	:	972-233-7030

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	07/08/2007

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