Provider Demographics
NPI:1942684212
Name:WILFONG, JESSICA (NP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WILFONG
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 1:1500 OAKLAND PL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76103-1550
Mailing Address - Country:US
Mailing Address - Phone:817-652-3395
Mailing Address - Fax:817-534-6141
Practice Address - Street 1:14041 NORTHWEST BLVD STE 1
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410
Practice Address - Country:US
Practice Address - Phone:361-767-9963
Practice Address - Fax:361-767-8477
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX877155363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily