Healthcare Provider Details

I. General information

NPI: 1679516652
Provider Name (Legal Business Name): JENNIFER MARIE BONTREGER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER MARIE HEIST DO

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 12/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2014 JUSTIN RD SUITE 104
HIGHLAND VILLAGE TX
75077-7161
US

IV. Provider business mailing address

2014 JUSTIN RD STE 104
LEWISVILLE TX
75077-7182
US

V. Phone/Fax

Practice location:
  • Phone: 469-645-0200
  • Fax: 469-637-0000
Mailing address:
  • Phone: 469-645-0200
  • Fax: 469-637-0000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberN4954
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: