Provider Demographics
NPI:1932593647
Name:DISHAW, JESSE
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:DISHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14590 MIDWAY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-3109
Mailing Address - Country:US
Mailing Address - Phone:972-510-7707
Mailing Address - Fax:972-767-0071
Practice Address - Street 1:14590 MIDWAY RD STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-3109
Practice Address - Country:US
Practice Address - Phone:972-510-7707
Practice Address - Fax:972-767-0071
Is Sole Proprietor?:No
Enumeration Date:2015-03-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3-20561-9801-6171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator