Provider Demographics
NPI:1780491001
Name:BOHANNON, JESSICA FAYE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:FAYE
Last Name:BOHANNON
Suffix:
Gender:
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4161 COUNTY ROAD 2727
Mailing Address - Street 2:
Mailing Address - City:CADDO MILLS
Mailing Address - State:TX
Mailing Address - Zip Code:75135-5624
Mailing Address - Country:US
Mailing Address - Phone:903-461-4100
Mailing Address - Fax:
Practice Address - Street 1:2710 SUNSET STRIP STE D
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75402-3849
Practice Address - Country:US
Practice Address - Phone:903-321-3151
Practice Address - Fax:903-418-3485
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-11
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1179922363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health