Healthcare Provider Details

I. General information

NPI: 1063214237
Provider Name (Legal Business Name): JESSICA TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 SOUTHTOWN DR STE 106
GRANBURY TX
76048-2667
US

IV. Provider business mailing address

7328 MISTLETOE TRL
GRANBURY TX
76048-3312
US

V. Phone/Fax

Practice location:
  • Phone: 855-579-5323
  • Fax:
Mailing address:
  • Phone: 574-206-3353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number205958
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: