=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932685682
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER MARIE WIERNAS OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2018
-----------------------------------------------------
Last Update Date | 07/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6333 CAMP BOWIE BLVD STE 272
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76116-5444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-738-9301
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3611 LAKE POWELL DR
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76016-3513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-905-5903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 9415TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------