MEDICARE: JESSICA MARIE HERNANDEZ OD

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	152W00000X	Optometrist	10964T	TX

General Provider Information

NPI Number	:	1891566873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA MARIE HERNANDEZ OD

Provider Business Mailing Address
First Line	:	6203 SUN DIAL ST
Second Line	:
City	:	LEON VALLEY
State	:	TX
Zip	:	78238-1544
Country	:	US
Telephone Number	:	210-288-9861
Fax Number	:

Provider Business Practice Location Address
First Line	:	4553 N LOOP 1604 W STE 1225
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249-1365
Country	:	US
Telephone Number	:	210-251-2372
Fax Number	:

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

Provider Enumeration Date	:	01/10/2024
Last Update Date	:	01/10/2024

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