Provider Demographics
NPI:1083269559
Name:MOORE, JESSICA M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:MONTALVO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CLEMENTS UNIVERSITY HOSPITAL 6201 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-6413
Practice Address - Country:US
Practice Address - Phone:214-288-6465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12964363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant