Healthcare Provider Details

I. General information

NPI: 1891580957
Provider Name (Legal Business Name): JESSICA MICHELLE KRICKBAUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2025
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 DECKER DRIVE
IRVING TX
75062-3999
US

IV. Provider business mailing address

919 MEDICAL DR STE 1100
ALLEN TX
75013-5756
US

V. Phone/Fax

Practice location:
  • Phone: 214-249-8410
  • Fax:
Mailing address:
  • Phone: 214-435-3255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-78192
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: