Provider Demographics
NPI:1376168823
Name:MYLES, JESSIKA D
Entity Type:Individual
Prefix:
First Name:JESSIKA
Middle Name:D
Last Name:MYLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15730 WISTERIA HILL ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77073-5692
Mailing Address - Country:US
Mailing Address - Phone:504-316-1538
Mailing Address - Fax:
Practice Address - Street 1:15730 WISTERIA HILL ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77073-5692
Practice Address - Country:US
Practice Address - Phone:504-316-1538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA009625572343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)