Healthcare Provider Details

I. General information

NPI: 1508093733
Provider Name (Legal Business Name): JENNIFFIER EADY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFFIER EADY MD

II. Dates (important events)

Enumeration Date: 06/15/2009
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 N KIMBALL AVE STE 120
SOUTHLAKE TX
76092-5570
US

IV. Provider business mailing address

5 WOODLANDS CT
TROPHY CLUB TX
76262-9735
US

V. Phone/Fax

Practice location:
  • Phone: 682-651-8007
  • Fax: 844-750-0657
Mailing address:
  • Phone: 972-310-8872
  • Fax: 844-750-0657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberP4593
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: