Provider Demographics
NPI:1093296113
Name:MACK, JESSICA CHRISTINA (LVN)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:CHRISTINA
Last Name:MACK
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:CHRISTINA
Other - Last Name:NAVARRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:
Mailing Address - City:LA COSTE
Mailing Address - State:TX
Mailing Address - Zip Code:78039-0043
Mailing Address - Country:US
Mailing Address - Phone:210-627-0781
Mailing Address - Fax:
Practice Address - Street 1:8610 N NEW BRAUNFELS AVE STE 405
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-6358
Practice Address - Country:US
Practice Address - Phone:210-804-0193
Practice Address - Fax:210-610-8782
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX317848251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care