MEDICARE: JESSICA EVANS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164X00000X	Licensed Vocational Nurse	346381	TX

General Provider Information

NPI Number	:	1255804571
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA EVANS

Provider Business Mailing Address
First Line	:	12903 SUGAR RIDGE BLVD APT 3004
Second Line	:
City	:	STAFFORD
State	:	TX
Zip	:	77477-3141
Country	:	US
Telephone Number	:	985-709-7663
Fax Number	:

Provider Business Practice Location Address
First Line	:	12903 SUGAR RIDGE BLVD APT 3004
Second Line	:
City	:	STAFFORD
State	:	TX
Zip	:	77477-3141
Country	:	US
Telephone Number	:	985-709-7663
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2019
Last Update Date	:	01/09/2019

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Directions to “ JESSICA EVANS ” Practice Location

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