Healthcare Provider Details

I. General information

NPI: 1801543962
Provider Name (Legal Business Name): JENNIFER MARIE RAE APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2022
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 FLORIDA DR.
ARLINGTON TX
76015
US

IV. Provider business mailing address

PO BOX 3132
RIDGELAND MS
39158
US

V. Phone/Fax

Practice location:
  • Phone: 817-277-1329
  • Fax:
Mailing address:
  • Phone: 970-699-0260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1164878
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: