Healthcare Provider Details

I. General information

NPI: 1740908771
Provider Name (Legal Business Name): JESSICA MENDEZ GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 MYER LN
KERMIT TX
79745-4634
US

IV. Provider business mailing address

132 ARAPAHO
ODESSA TX
79763-7853
US

V. Phone/Fax

Practice location:
  • Phone: 432-586-2040
  • Fax:
Mailing address:
  • Phone: 432-312-6624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18461
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: