Provider Demographics
NPI:1861122160
Name:PACKARD, JESSICA LANE
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:LANE
Last Name:PACKARD
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 1:10111 ROSEBERRY DR
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:TX
Mailing Address - Zip Code:77571-2914
Mailing Address - Country:US
Mailing Address - Phone:210-660-9976
Mailing Address - Fax:
Practice Address - Street 1:10111 ROSEBERRY DR
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:TX
Practice Address - Zip Code:77571-2914
Practice Address - Country:US
Practice Address - Phone:210-660-9976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant