Basic Information
| Provider Information | |||||||||
| NPI: | 1861696643 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOONEY | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2710 SWISS AVE | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752045900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148211599 | ||||||||
| FaxNumber: | 2148218985 | ||||||||
| Practice Location | |||||||||
| Address1: | 2710 SWISS AVE | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752045900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1482115992 | ||||||||
| FaxNumber: | 2148218985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 10/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 205553 | LA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | N7301 | TX | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | 205553 | LA | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0102X | N7301 | TX | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | N7301 | TX | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0127X | 205553 | LA | Y | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2304178 | 05 | LA | MEDICAID |