=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588115455
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JENNIFER WEATHERLY D.O.P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2016
-----------------------------------------------------
Last Update Date | 10/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3250 W PLEASANT RUN RD STE 160
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75146-1071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-274-5200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3250 W PLEASANT RUN RD STE 160
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75146-1071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-274-5200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | JENNIFER WEATHERLY
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 972-274-5200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------