Basic Information
| Provider Information | |||||||||
| NPI: | 1700975398 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHELLOCK | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6020 W PARKER RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750938172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724733947 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6020 W PARKER RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750938172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9726085000 | ||||||||
| FaxNumber: | 9724733929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 06/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | M9650 | TX | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | M9650 | 01 | TX | TEXAS MEDICAL LICENSE | OTHER |