Provider Demographics
NPI:1679513907
Name:LIVINGSTON, JENNIFER R (PA)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:R
Last Name:LIVINGSTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:R
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:108 S. WILLIAM BARNETT AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TX
Mailing Address - Zip Code:77327
Mailing Address - Country:US
Mailing Address - Phone:281-659-2355
Mailing Address - Fax:281-592-1570
Practice Address - Street 1:309 HWY 59 S. LOOP
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351
Practice Address - Country:US
Practice Address - Phone:281-659-2355
Practice Address - Fax:281-592-1570
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-000866363A00000X
TXPA07825363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
438476YQBEMedicare UPIN
P28906Medicare UPIN
K05366Medicare ID - Type UnspecifiedGROUP NO. 208476
K04980Medicare ID - Type UnspecifiedGROUP NO. 208627