Provider Demographics
NPI:1407327224
Name:ROTH, JESSICA ANN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ANN
Other - Last Name:ROTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 206239
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-6239
Mailing Address - Country:US
Mailing Address - Phone:214-424-2200
Mailing Address - Fax:469-547-5339
Practice Address - Street 1:900 W MAGNOLIA AVE STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-8518
Practice Address - Country:US
Practice Address - Phone:817-870-7300
Practice Address - Fax:817-332-5117
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-06
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138318363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP138318OtherNURSE PRACTIONER