Healthcare Provider Details

I. General information

NPI: 1497315154
Provider Name (Legal Business Name): JENNIFER R MIXSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2019
Last Update Date: 06/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6836 BEE CAVES RD # 310
AUSTIN TX
78746-5059
US

IV. Provider business mailing address

750 COUNTY ROAD 130
GEORGETOWN TX
78626-2221
US

V. Phone/Fax

Practice location:
  • Phone: 512-383-5204
  • Fax:
Mailing address:
  • Phone: 512-635-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP141880
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: