Provider Demographics
NPI:1548527948
Name:ANDERSON, JENEA ANTIONETTE
Entity type:Individual
Prefix:
First Name:JENEA
Middle Name:ANTIONETTE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 PINCHBACK RD
Mailing Address - Street 2:402
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77707-3226
Mailing Address - Country:US
Mailing Address - Phone:409-223-9604
Mailing Address - Fax:
Practice Address - Street 1:1075 PINCHBACK RD
Practice Address - Street 2:402
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-3226
Practice Address - Country:US
Practice Address - Phone:409-223-9604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2012-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor