Healthcare Provider Details

I. General information

NPI: 1508318528
Provider Name (Legal Business Name): JENNA LANE EVERETT PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 N MAIN
LOCKNEY TX
79241
US

IV. Provider business mailing address

PO BOX 37
LOCKNEY TX
79241-0037
US

V. Phone/Fax

Practice location:
  • Phone: 806-652-3373
  • Fax: 806-652-2417
Mailing address:
  • Phone: 806-652-3373
  • Fax: 806-652-2417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: