=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306300090
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAREKA LYNNE ANDERSON APRN, FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2019
-----------------------------------------------------
Last Update Date | 02/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 S CLAY ST STE 104
-----------------------------------------------------
City | ENNIS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75119-5771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-875-6600
-----------------------------------------------------
Fax | 877-460-4501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 S CLAY ST STE 104
-----------------------------------------------------
City | ENNIS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75119-5771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-221-6605
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | AP140317
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | AP140317
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | AP140317
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number | AP140317
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | AP140317
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------