Healthcare Provider Details

I. General information

NPI: 1417293960
Provider Name (Legal Business Name): JENNA LOGAN DAVISON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA LOGAN BREWER

II. Dates (important events)

Enumeration Date: 01/02/2013
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7801 OAKMONT BLVD STE 101
FT WORTH TX
76132-4204
US

IV. Provider business mailing address

7801 OAKMONT BLVD STE 101
FT WORTH TX
76132-4204
US

V. Phone/Fax

Practice location:
  • Phone: 817-263-0007
  • Fax: 817-263-1118
Mailing address:
  • Phone: 817-263-0007
  • Fax: 817-263-1118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA08103
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: