Provider Demographics
NPI:1649865387
Name:KHAMVONGSA, JESSICA
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:KHAMVONGSA
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 1:2812 JASMINE CT
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-2703
Mailing Address - Country:US
Mailing Address - Phone:817-505-3488
Mailing Address - Fax:
Practice Address - Street 1:2812 JASMINE CT
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-2703
Practice Address - Country:US
Practice Address - Phone:817-505-3488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies