Provider Demographics
NPI:1558146837
Name:MORENO, JESSICA (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W MAIN ST STE 220
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-4224
Mailing Address - Country:US
Mailing Address - Phone:214-351-3490
Mailing Address - Fax:
Practice Address - Street 1:120 W MAIN ST STE 220
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-4224
Practice Address - Country:US
Practice Address - Phone:214-351-3490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1081657363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health