Provider Demographics
NPI:1417323643
Name:AGWUMARO, JESSICA (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:AGWUMARO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3804 MEREDITH LN
Mailing Address - Street 2:
Mailing Address - City:BALCH SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75180-5016
Mailing Address - Country:US
Mailing Address - Phone:214-609-7985
Mailing Address - Fax:
Practice Address - Street 1:8062 FERGUSON RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-5848
Practice Address - Country:US
Practice Address - Phone:214-327-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09778363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical