Provider Demographics
NPI:1649886292
Name:DANIELS, JESSICA ELIZABETH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ELIZABETH
Last Name:DANIELS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:ELIZABETH
Other - Last Name:DOMINGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9000 SAGEWOOD DR APT 10103
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76177-2287
Mailing Address - Country:US
Mailing Address - Phone:817-937-9443
Mailing Address - Fax:
Practice Address - Street 1:6161 N STATE HWY 161 #200
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2220
Practice Address - Country:US
Practice Address - Phone:972-258-7499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-18
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
TXPA13973208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant