Healthcare Provider Details

I. General information

NPI: 1134784838
Provider Name (Legal Business Name): JENNIFER NICOLE SKILES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 MEDICAL DR STE A
TYLER TX
75701-2143
US

IV. Provider business mailing address

1107 E MARSHALL AVE
LONGVIEW TX
75601-5602
US

V. Phone/Fax

Practice location:
  • Phone: 903-758-2610
  • Fax: 903-758-7081
Mailing address:
  • Phone: 903-758-2610
  • Fax: 903-758-7081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP140574
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAP140574
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP140574
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: