Provider Demographics
NPI:1710505136
Name:RESENDEZ, JILL (NP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:RESENDEZ
Suffix:
Gender:F
Credentials:NP
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 650859 DEPT 710
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-1910
Mailing Address - Country:US
Mailing Address - Phone:409-772-3620
Mailing Address - Fax:409-772-1084
Practice Address - Street 1:16030 CAPISTRANO FALLS DR
Practice Address - Street 2:
Practice Address - City:FRIENDSWOOD
Practice Address - State:TX
Practice Address - Zip Code:77546-2442
Practice Address - Country:US
Practice Address - Phone:832-526-7367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1008458363LG0600X
TX2020038365363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2020038365Medicaid