Provider Demographics
NPI:1740908771
Name:GONZALEZ, JESSICA MENDEZ
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MENDEZ
Last Name:GONZALEZ
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 1:132 ARAPAHO
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763-7853
Mailing Address - Country:US
Mailing Address - Phone:432-312-6624
Mailing Address - Fax:
Practice Address - Street 1:828 MYER LN
Practice Address - Street 2:
Practice Address - City:KERMIT
Practice Address - State:TX
Practice Address - Zip Code:79745-4634
Practice Address - Country:US
Practice Address - Phone:432-586-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-16
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA18461363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program