Basic Information
| Provider Information | |||||||||
| NPI: | 1407093735 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUKHERJEE | ||||||||
| FirstName: | JEANIECE | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 162835 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761612835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173340530 | ||||||||
| FaxNumber: | 8173340235 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 LIPSCOMB ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173488600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2009 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 678919 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 00N47F | 01 | TX | MEDICARE GROUP NUMBER | OTHER | 199310708 | 05 | TX | MEDICAID | 199310702 | 05 | TX | MEDICAID | 140442853 | 01 | TX | CSHCN GROUP NUMBER | OTHER | 199310703 | 01 | TX | CSHCN | OTHER | 137345809 | 01 | TX | MEDICAID GROUP NUMBER | OTHER |