Basic Information
| Provider Information | |||||||||
| NPI: | 1659980811 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUSTANCE | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 840853 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752840853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146872100 | ||||||||
| FaxNumber: | 9725182100 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146870001 | ||||||||
| FaxNumber: | 9725182100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2020 | ||||||||
| LastUpdateDate: | 02/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 830019 | TX | N | Nursing Service Providers | Registered Nurse | 367500000X | 1027207 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.