Provider Demographics
NPI:1093182263
Name:NUNNALLY, JESSICA JUNE (CPNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JUNE
Last Name:NUNNALLY
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:JUNE
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1860
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:801 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2733
Practice Address - Country:US
Practice Address - Phone:682-885-4095
Practice Address - Fax:682-885-7499
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX773534363LP0200X
TXAP129113363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics