Healthcare Provider Details

I. General information

NPI: 1255802963
Provider Name (Legal Business Name): JENNIFER COCKRUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2018
Last Update Date: 12/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BSA HOSPITALIST 1600 WALLACE BLVD.
AMARILLO TX
79106
US

IV. Provider business mailing address

PO BOX 840026
DALLAS TX
75284-0026
US

V. Phone/Fax

Practice location:
  • Phone: 806-212-2129
  • Fax: 806-212-2246
Mailing address:
  • Phone: 806-212-6965
  • Fax: 806-212-6278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberAP139848
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: