Provider Demographics
NPI:1578130811
Name:PATTERSON, JASEY KELNE (PA-C)
Entity Type:Individual
Prefix:
First Name:JASEY
Middle Name:KELNE
Last Name:PATTERSON
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 1:240 JEFFERSON PKWY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-1884
Mailing Address - Country:US
Mailing Address - Phone:832-722-3407
Mailing Address - Fax:
Practice Address - Street 1:823 IRA E WOODS AVE STE 200
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-4096
Practice Address - Country:US
Practice Address - Phone:817-722-6078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTEMPORARY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant