=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821072414
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER ELICE ORTEGA R.PH.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 W ROSEDALE ST
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-4621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-920-6722
-----------------------------------------------------
Fax | 817-920-6748
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 W ROSEDALE ST
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-4621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-920-6722
-----------------------------------------------------
Fax | 817-920-6748
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P1200X
-----------------------------------------------------
Taxonomy Name | Pharmacotherapy Pharmacist
-----------------------------------------------------
License Number | 33853
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------