Healthcare Provider Details

I. General information

NPI: 1194073999
Provider Name (Legal Business Name): JENNIFER ELISE DIERKSEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 10/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6431 FANNIN ST MSB 2.262
HOUSTON TX
77030-1501
US

IV. Provider business mailing address

6431 FANNIN ST MSB 2.262
HOUSTON TX
77030-1501
US

V. Phone/Fax

Practice location:
  • Phone: 713-500-5302
  • Fax:
Mailing address:
  • Phone: 903-241-1175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: