Provider Demographics
NPI:1821080136
Name:ACEVEDO-GRACIA, JESSICA I (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:I
Last Name:ACEVEDO-GRACIA
Suffix:
Gender:F
Credentials:MD
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 61160
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-1160
Mailing Address - Country:US
Mailing Address - Phone:361-884-2904
Mailing Address - Fax:361-884-1912
Practice Address - Street 1:5817 PATTON ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414
Practice Address - Country:US
Practice Address - Phone:361-992-9383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9052208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX172865101Medicaid
TX172865101Medicaid