Provider Demographics
NPI:1174205025
Name:PERALTA, JESSICA (MSN, APRN, FNP- BC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PERALTA
Suffix:
Gender:F
Credentials:MSN, APRN, FNP- BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 NASHVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1105
Mailing Address - Country:US
Mailing Address - Phone:806-725-5844
Mailing Address - Fax:806-723-6532
Practice Address - Street 1:3601 21ST ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1229
Practice Address - Country:US
Practice Address - Phone:806-791-0399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-01
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1130833363LF0000X
TX772024163WN0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WN0800XNursing Service ProvidersRegistered NurseNeuroscience