Provider Demographics
NPI:1538721246
Name:SIMON, JESSICA M
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:SIMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 S MAYS ST STE 201
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-7580
Mailing Address - Country:US
Mailing Address - Phone:512-244-4272
Mailing Address - Fax:
Practice Address - Street 1:3500 HILLCREST DR STE 1
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-3144
Practice Address - Country:US
Practice Address - Phone:254-741-6641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF06191496363L00000X
TXAP142254363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX405277101Medicaid