Provider Demographics
NPI:1861029522
Name:WALDREP, JESSICA RENEE (LAT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENEE
Last Name:WALDREP
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 SECOND ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:TX
Mailing Address - Zip Code:75758-2235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10064 STATE HIGHWAY SPUR 264
Practice Address - Street 2:
Practice Address - City:QUINLAN
Practice Address - State:TX
Practice Address - Zip Code:75474-8743
Practice Address - Country:US
Practice Address - Phone:903-356-1680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT63392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer