MEDICARE: ANAMARINA JARECKE C-PNP

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	363LP0200X	Pediatric Nurse Practitioner	847886	TX

General Provider Information

NPI Number	:	1447535463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANAMARINA JARECKE C-PNP

Provider Business Mailing Address
First Line	:	1412 MAY ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-7639
Country	:	US
Telephone Number	:	817-702-2450
Fax Number	:	817-702-7315

Provider Business Practice Location Address
First Line	:	5300 BUCHANAN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76114-1304
Country	:	US
Telephone Number	:	817-702-5066
Fax Number	:	817-252-2588

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

Provider Enumeration Date	:	10/21/2011
Last Update Date	:	07/21/2022

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