Provider Demographics
NPI:1396024923
Name:WASHINGTON, JESSICA LA'NELLE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LA'NELLE
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LA'NELLE
Other - Last Name:WASHINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4415 MENZER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76103-1817
Mailing Address - Country:US
Mailing Address - Phone:817-507-3239
Mailing Address - Fax:
Practice Address - Street 1:4415 MENZER RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76103-1817
Practice Address - Country:US
Practice Address - Phone:817-507-3239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-13
Last Update Date:2014-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator