Basic Information
| Provider Information | |||||||||
| NPI: | 1821080136 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ACEVEDO-GRACIA | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 61160 | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784661160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3618842904 | ||||||||
| FaxNumber: | 3618841912 | ||||||||
| Practice Location | |||||||||
| Address1: | 5817 PATTON ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3619929383 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 06/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | L9052 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 172865101 | 05 | TX | MEDICAID |