Provider Demographics
NPI:1295406262
Name:TIBBS, JESSICA ALYSE (OD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ALYSE
Last Name:TIBBS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1838
Mailing Address - Street 2:
Mailing Address - City:CENTER
Mailing Address - State:TX
Mailing Address - Zip Code:75935-1838
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:702 LOUISIANA ST
Practice Address - Street 2:
Practice Address - City:CENTER
Practice Address - State:TX
Practice Address - Zip Code:75935-3672
Practice Address - Country:US
Practice Address - Phone:936-598-8501
Practice Address - Fax:936-598-2311
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10420T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist