Healthcare Provider Details

I. General information

NPI: 1619617065
Provider Name (Legal Business Name): JESSE SUPERNAW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2022
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 S 31ST ST
TEMPLE TX
76508-0001
US

IV. Provider business mailing address

PO BOX 844658
DALLAS TX
75284-4658
US

V. Phone/Fax

Practice location:
  • Phone: 254-724-5306
  • Fax:
Mailing address:
  • Phone: 800-994-0371
  • Fax: 254-215-9722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberW7465
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: