Healthcare Provider Details

I. General information

NPI: 1780976167
Provider Name (Legal Business Name): JENNIFER L GRANT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER BARTHOLOMEW M.D.

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 PENNSYLVANIA AVE
FORT WORTH TX
76104-2158
US

IV. Provider business mailing address

DEPARTMENT OF SURGERY UT SOUTHWESTERN MEDICAL CENTER 5323 HARRY HINES BLVD
DALLAS TX
75390-9159
US

V. Phone/Fax

Practice location:
  • Phone: 817-761-7740
  • Fax:
Mailing address:
  • Phone: 214-648-3917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberQ9621
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberQ9621
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: