Healthcare Provider Details

I. General information

NPI: 1154929669
Provider Name (Legal Business Name): JENNER HERNANDEZ APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2020
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 S OLD BETSY RD UNIT 686
KEENE TX
76059-2922
US

IV. Provider business mailing address

203 S OLD BETSY RD UNIT 686
KEENE TX
76059-2922
US

V. Phone/Fax

Practice location:
  • Phone: 817-995-5704
  • Fax:
Mailing address:
  • Phone: 817-995-5704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1016976
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number325935
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: