Provider Demographics
NPI:1508623273
Name:LICEA, JESSICA LOUISE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LOUISE
Last Name:LICEA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LOUISE
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:105 FM 1996
Mailing Address - Street 2:
Mailing Address - City:OGLESBY
Mailing Address - State:TX
Mailing Address - Zip Code:76561-2014
Mailing Address - Country:US
Mailing Address - Phone:254-339-5456
Mailing Address - Fax:
Practice Address - Street 1:510 N HEWITT DR
Practice Address - Street 2:
Practice Address - City:HEWITT
Practice Address - State:TX
Practice Address - Zip Code:76643-3038
Practice Address - Country:US
Practice Address - Phone:254-420-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant