Provider Demographics
NPI:1861696643
Name:MOONEY, JENNIFER L (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:MOONEY
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 1:2710 SWISS AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-5900
Mailing Address - Country:US
Mailing Address - Phone:214-821-1599
Mailing Address - Fax:214-821-8985
Practice Address - Street 1:2710 SWISS AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-5900
Practice Address - Country:US
Practice Address - Phone:148-211-5992
Practice Address - Fax:214-821-8985
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA205553208600000X, 2086S0102X, 2086S0127X
TXN7301208600000X, 2086S0102X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2304178Medicaid
LA2304178Medicaid