Provider Demographics
NPI:1659980811
Name:CUSTANCE, JESSICA MARIE (RN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:CUSTANCE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:214-687-2100
Mailing Address - Fax:972-518-2100
Practice Address - Street 1:1400 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4110
Practice Address - Country:US
Practice Address - Phone:214-687-0001
Practice Address - Fax:972-518-2100
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX830019163W00000X
TX1027207367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse