MEDICARE: JENNA LOGAN DAVISON PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA08103	TX

General Provider Information

NPI Number	:	1417293960
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA LOGAN DAVISON PA

Provider Business Mailing Address
First Line	:	7801 OAKMONT BLVD
Second Line	:	STE 101
City	:	FT WORTH
State	:	TX
Zip	:	76132-4204
Country	:	US
Telephone Number	:	817-263-0007
Fax Number	:	817-263-1118

Provider Business Practice Location Address
First Line	:	7801 OAKMONT BLVD
Second Line	:	STE 101
City	:	FT WORTH
State	:	TX
Zip	:	76132-4204
Country	:	US
Telephone Number	:	817-263-0007
Fax Number	:	817-263-1118

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2013
Last Update Date	:	11/17/2020

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Directions to “ JENNA LOGAN DAVISON PA” Practice Location

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