Provider Demographics
NPI:1730195090
Name:PANNELL, JENNIFER C (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:PANNELL
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:PO BOX 26726
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-0726
Mailing Address - Country:US
Mailing Address - Phone:512-407-8686
Mailing Address - Fax:512-421-4489
Practice Address - Street 1:1807 W SLAUGHTER LN
Practice Address - Street 2:#490
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-6208
Practice Address - Country:US
Practice Address - Phone:512-282-8967
Practice Address - Fax:512-292-5143
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6560208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170903202Medicaid
TX170903204Medicaid
TX170903203Medicaid
TX170903201Medicaid
TX170903201Medicaid
TXTXB118929Medicare PIN
TX170903202Medicaid
TXTXB118931Medicare PIN