Provider Demographics
NPI:1689094559
Name:WILDE, JESSICA (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WILDE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:THIBODEAUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:17510 DELL CITY DR
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-7255
Mailing Address - Country:US
Mailing Address - Phone:979-204-1742
Mailing Address - Fax:
Practice Address - Street 1:4611 GUADALUPE ST STE 200
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78751-2928
Practice Address - Country:US
Practice Address - Phone:512-476-2830
Practice Address - Fax:512-476-2832
Is Sole Proprietor?:No
Enumeration Date:2014-04-18
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant