Provider Demographics
NPI:1912946484
Name:TREVINO, JESSICA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:TREVINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9211 WATERFORD CENTRE BLVD
Mailing Address - Street 2:#200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-7667
Mailing Address - Country:US
Mailing Address - Phone:512-420-0186
Mailing Address - Fax:512-420-0397
Practice Address - Street 1:9211 WATERFORD CENTRE BLVD
Practice Address - Street 2:#200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-7667
Practice Address - Country:US
Practice Address - Phone:512-420-0186
Practice Address - Fax:512-420-0397
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTEMPORARY207R00000X
TXM3769207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX317657003Medicaid
TX317657003Medicaid