Provider Demographics
NPI:1417287046
Name:LIESVELD, JEREMY J (DC, FNP-C)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:J
Last Name:LIESVELD
Suffix:
Gender:M
Credentials:DC, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6161 N STATE HIGHWAY 161
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-2220
Mailing Address - Country:US
Mailing Address - Phone:972-258-7499
Mailing Address - Fax:972-257-0897
Practice Address - Street 1:6161 N HIGHWAY 161
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038
Practice Address - Country:US
Practice Address - Phone:972-258-7499
Practice Address - Fax:973-257-0897
Is Sole Proprietor?:No
Enumeration Date:2010-01-04
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11339111N00000X
TXAP128486363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No111N00000XChiropractic ProvidersChiropractor