Basic Information
| Provider Information | |||||||||
| NPI: | 1760030100 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARREON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | KATHRYN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EBELING | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | KATHRYN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5012 S US HIGHWAY 75 STE 300 | ||||||||
| Address2: | ATTN BILLING | ||||||||
| City: | DENISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750204587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063517530 | ||||||||
| FaxNumber: | 8063517538 | ||||||||
| Practice Location | |||||||||
| Address1: | 1411 E AMARILLO BLVD | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791075555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063517200 | ||||||||
| FaxNumber: | 8063517274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2019 | ||||||||
| LastUpdateDate: | 11/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP142879 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1A9386 | 01 | TX | MEDICARE | OTHER | 4110488-01 | 05 | TX | MEDICAID | 1W2796 | 01 | TX | PTAN | OTHER |