Provider Demographics
NPI:1184733420
Name:BRACE, JESSICA POLK (DC)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:POLK
Last Name:BRACE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-3177
Mailing Address - Country:US
Mailing Address - Phone:817-444-2170
Mailing Address - Fax:817-270-3338
Practice Address - Street 1:237 W MAIN ST
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-3177
Practice Address - Country:US
Practice Address - Phone:817-444-2170
Practice Address - Fax:817-270-3338
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9732111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8R3130OtherBLUE CROSS BLUE SHIELD
TX8R3130OtherBLUE CROSS BLUE SHIELD
TXV02376Medicare UPIN