Basic Information
| Provider Information | |||||||||
| NPI: | 1073056370 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STODIECK | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | AGACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 MISTLETOE BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173381300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 209 OLD HIGHWAY 1187 | ||||||||
| Address2: | |||||||||
| City: | BURLESON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173381300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2016 | ||||||||
| LastUpdateDate: | 03/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | AP132562 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363L00000X | AP132562 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 390229801 | 05 | TX | MEDICAID |