Provider Demographics
NPI:1336413228
Name:BACA, JESSICA ANNA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNA
Last Name:BACA
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 1:15703 S BRENTWOOD ST
Mailing Address - Street 2:
Mailing Address - City:CHANNELVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:77530-4019
Mailing Address - Country:US
Mailing Address - Phone:832-338-6123
Mailing Address - Fax:
Practice Address - Street 1:12605 EAST FWY
Practice Address - Street 2:SUITE 200
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77015-5625
Practice Address - Country:US
Practice Address - Phone:713-453-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106763235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist