Provider Demographics
NPI:1447535463
Name:JARECKE, ANAMARINA (C-PNP)
Entity type:Individual
Prefix:
First Name:ANAMARINA
Middle Name:
Last Name:JARECKE
Suffix:
Gender:F
Credentials:C-PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 MAY ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7639
Mailing Address - Country:US
Mailing Address - Phone:817-702-2450
Mailing Address - Fax:817-702-7315
Practice Address - Street 1:5300 BUCHANAN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76114-1304
Practice Address - Country:US
Practice Address - Phone:817-702-5066
Practice Address - Fax:817-252-2588
Is Sole Proprietor?:No
Enumeration Date:2011-10-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX847886363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX293795501Medicaid