Provider Demographics
NPI:1134556145
Name:HEREDIA, JESSICA LEE
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LEE
Last Name:HEREDIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 W PIKE BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:WESLACO
Mailing Address - State:TX
Mailing Address - Zip Code:78596-4706
Mailing Address - Country:US
Mailing Address - Phone:956-647-5061
Mailing Address - Fax:956-647-5157
Practice Address - Street 1:413 W PIKE BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-4706
Practice Address - Country:US
Practice Address - Phone:956-647-5061
Practice Address - Fax:956-647-5157
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80553237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist