Provider Demographics
NPI:1124628557
Name:BUCHANAN, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BUCHANAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:WIETHOLTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:800-994-0371
Mailing Address - Fax:254-215-9722
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-0001
Practice Address - Country:US
Practice Address - Phone:254-724-2111
Practice Address - Fax:254-724-7603
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0031212363L00000X
TX1017806363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner