Healthcare Provider Details

I. General information

NPI: 1053127902
Provider Name (Legal Business Name): JENNIFER LYNN OTWAY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 NORTH HERITAGE PARKWAY
SHERMAN TX
75092
US

IV. Provider business mailing address

400 S CULBERSON ST APT 8308
GAINESVILLE TX
76240-3860
US

V. Phone/Fax

Practice location:
  • Phone: 903-308-4336
  • Fax: 903-771-4541
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1180755
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: