Provider Demographics
NPI:1518210442
Name:CONRAD, JESSICA SUZANNE (PNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUZANNE
Last Name:CONRAD
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:SUZANNE
Other - Last Name:COCHRANE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:1500 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:682-885-7960
Practice Address - Fax:682-885-1327
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX749722363LP0200X
TXAP122648363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45-2578435OtherTRICARE
TX8045NUOtherBCBS
TXP01635751OtherRAIL ROAD MEDICARE
TX344212102Medicaid
TXP01635751OtherRAIL ROAD MEDICARE