Healthcare Provider Details

I. General information

NPI: 1386093672
Provider Name (Legal Business Name): JENNIE MATHEW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N PRESTON RD STE 20
PROSPER TX
75078-8891
US

IV. Provider business mailing address

1000 N PRESTON RD STE 20
PROSPER TX
75078-8891
US

V. Phone/Fax

Practice location:
  • Phone: 469-296-8030
  • Fax: 888-851-4582
Mailing address:
  • Phone: 469-296-8030
  • Fax: 888-851-4582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34728
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMT211153
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: