Provider Demographics
NPI:1225016413
Name:KISNER, JENNY (OD)
Entity type:Individual
Prefix:DR
First Name:JENNY
Middle Name:
Last Name:KISNER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:
Other - Last Name:BRUNGARDT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1508 BROOK AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-5604
Mailing Address - Country:US
Mailing Address - Phone:940-761-2317
Mailing Address - Fax:940-761-2992
Practice Address - Street 1:1508 BROOK AVE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-5604
Practice Address - Country:US
Practice Address - Phone:940-761-2317
Practice Address - Fax:940-761-2992
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6311TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1550295-01Medicaid
TX155029505Medicaid
TX155029505Medicaid
TX1550295-01Medicaid
TX613831Medicare PIN