Provider Demographics
NPI:1720621071
Name:LERTDILOK, JEFFREY JESSADA (FNP-C)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JESSADA
Last Name:LERTDILOK
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4132 CATAWBA AVE
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-1196
Mailing Address - Country:US
Mailing Address - Phone:972-746-8250
Mailing Address - Fax:
Practice Address - Street 1:4100 FAIRWAY DR STE 320
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-6537
Practice Address - Country:US
Practice Address - Phone:972-236-7608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142915363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily