Healthcare Provider Details

I. General information

NPI: 1427515444
Provider Name (Legal Business Name): MRS. JESSICA DEN HERDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA RENAUDO

II. Dates (important events)

Enumeration Date: 02/26/2019
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 UNIVERSITY BLVD
GALVESTON TX
77555-2918
US

IV. Provider business mailing address

301 UNIVERSITY BLVD
GALVESTON TX
77555-7396
US

V. Phone/Fax

Practice location:
  • Phone: 832-505-2100
  • Fax: 409-747-3585
Mailing address:
  • Phone: 832-505-2100
  • Fax: 409-747-3585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP140585
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: