Healthcare Provider Details

I. General information

NPI: 1760926695
Provider Name (Legal Business Name): JANE ELIZABETH CLASSEN AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2016
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 8TH AVE
FORT WORTH TX
76110-1812
US

IV. Provider business mailing address

2221 8TH AVE
FORT WORTH TX
76110-1812
US

V. Phone/Fax

Practice location:
  • Phone: 817-336-5060
  • Fax: 817-336-1744
Mailing address:
  • Phone: 817-336-5060
  • Fax: 817-336-1744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP132738
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP132738
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: