Provider Demographics
NPI:1114007390
Name:STANGENWALD, JESSICA LYNN (DC, FNP)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:LYNN
Last Name:STANGENWALD
Suffix:
Gender:F
Credentials:DC, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GRAPEVINE HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054
Mailing Address - Country:US
Mailing Address - Phone:817-281-9040
Mailing Address - Fax:817-281-4249
Practice Address - Street 1:100 GRAPEVINE HIGHWAY
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054
Practice Address - Country:US
Practice Address - Phone:817-281-9040
Practice Address - Fax:817-281-4249
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10088111N00000X
TXAP129338363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
8F1514Medicare ID - Type Unspecified