Provider Demographics
NPI:1457952558
Name:WALLER, JESSICA L (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:L
Last Name:WALLER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MRS
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-C
Mailing Address - Street 1:1100 W. REYNOSA AVE.
Mailing Address - Street 2:
Mailing Address - City:DE LEON
Mailing Address - State:TX
Mailing Address - Zip Code:76444
Mailing Address - Country:US
Mailing Address - Phone:254-893-5895
Mailing Address - Fax:888-895-1214
Practice Address - Street 1:2100 CROCKETT DR.
Practice Address - Street 2:
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801-5120
Practice Address - Country:US
Practice Address - Phone:256-460-7043
Practice Address - Fax:888-895-1214
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1018050363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily