Provider Demographics
NPI:1962624346
Name:WURST, JODI LEANN (FNP)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:LEANN
Last Name:WURST
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 MISTLETOE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4050
Mailing Address - Country:US
Mailing Address - Phone:817-338-1300
Mailing Address - Fax:817-335-9871
Practice Address - Street 1:1900 MISTLETOE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4050
Practice Address - Country:US
Practice Address - Phone:817-338-1300
Practice Address - Fax:817-335-9871
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX652426363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198324901Medicaid
TX198324903Medicaid
TX198324902Medicaid
TX198324901Medicaid
TX8L4133Medicare PIN
TX8L4284Medicare PIN