Healthcare Provider Details

I. General information

NPI: 1891493250
Provider Name (Legal Business Name): JESSICA LYNNE CHILDRESS APRN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2023
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E DAWSON ST
TYLER TX
75701-2036
US

IV. Provider business mailing address

PO BOX 163
TROUP TX
75789-0163
US

V. Phone/Fax

Practice location:
  • Phone: 469-358-9369
  • Fax: 888-242-8720
Mailing address:
  • Phone: 903-330-1112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1110867
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: