=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952654725
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA MANN HESS ACNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2012
-----------------------------------------------------
Last Update Date | 10/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3615 CAMP BOWIE BLVD
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76107-3351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-737-2700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 250 GINGER CT
-----------------------------------------------------
City | SOUTHLAKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76092-6047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-233-3406
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 675112
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------