Healthcare Provider Details

I. General information

NPI: 1073012977
Provider Name (Legal Business Name): EBONY JENKINS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2018
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7232 NORTH FWY
FORT WORTH TX
76137
US

IV. Provider business mailing address

645 E STATE HIGHWAY 121 STE 600
COPPELL TX
75019-7942
US

V. Phone/Fax

Practice location:
  • Phone: 817-439-8100
  • Fax: 817-439-8103
Mailing address:
  • Phone: 972-745-7500
  • Fax: 972-745-4336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3012032
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number902428
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAP10921
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAP136189
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: