Provider Demographics
NPI:1700880515
Name:KEMMERER, JENNIFER DAWN (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:KEMMERER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:DAWN
Other - Last Name:DIBRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:690 S LOOP 336 WEST
Mailing Address - Street 2:STE 222
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-3320
Mailing Address - Country:US
Mailing Address - Phone:936-756-6661
Mailing Address - Fax:936-756-6681
Practice Address - Street 1:690 S LOOP 336 WEST
Practice Address - Street 2:STE 222
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-3320
Practice Address - Country:US
Practice Address - Phone:936-756-6661
Practice Address - Fax:936-756-6681
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1066468363AS0400X
TXPA04343363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ36680Medicare UPIN
TXTXB154738Medicare UPIN
TX8N7436Medicare ID - Type Unspecified