Provider Demographics
NPI:1720521354
Name:CANALES, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CANALES
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 1:3230 DESTINY POINT DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79938-5393
Mailing Address - Country:US
Mailing Address - Phone:915-253-2916
Mailing Address - Fax:
Practice Address - Street 1:4845 ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2705
Practice Address - Country:US
Practice Address - Phone:915-298-5444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-30
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX772023163WP0200X
TXAP132668363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000000Medicaid