Provider Demographics
NPI:1548297278
Name:STALKUP, JENNIFER R (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:R
Last Name:STALKUP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5016 MILAM ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-6512
Mailing Address - Country:US
Mailing Address - Phone:214-615-1900
Mailing Address - Fax:214-615-1800
Practice Address - Street 1:6100 WINDHAVEN PKWY
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-8046
Practice Address - Country:US
Practice Address - Phone:214-615-1900
Practice Address - Fax:214-615-1800
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1368207NP0225X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
612437Medicare ID - Type Unspecified
I54103Medicare UPIN