Basic Information
| Provider Information | |||||||||
| NPI: | 1992824791 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOLDENHAUER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 MAPLE AVE SUITE 108 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145263566 | ||||||||
| FaxNumber: | 2149408085 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 MAPLE AVE SUITE 108 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145263566 | ||||||||
| FaxNumber: | 2149408085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA05046 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.