Provider Demographics
NPI:1093950115
Name:SAMPLE, JESSICA BROOKE (RN, CPNP-PC)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:BROOKE
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:RN, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 FOREST LN STE B
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2571
Mailing Address - Country:US
Mailing Address - Phone:972-566-7730
Mailing Address - Fax:
Practice Address - Street 1:7777 FOREST LN STE B246
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-6816
Practice Address - Country:US
Practice Address - Phone:972-454-5288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-03
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX689425363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics