Provider Demographics
NPI:1023058815
Name:NORDSTROM, JESSICA GRACE (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:GRACE
Last Name:NORDSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4161 MCKINNEY AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-8233
Mailing Address - Country:US
Mailing Address - Phone:972-817-7040
Mailing Address - Fax:972-817-7050
Practice Address - Street 1:4161 MCKINNEY AVE STE 300
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-8233
Practice Address - Country:US
Practice Address - Phone:972-817-7040
Practice Address - Fax:972-817-7050
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9399207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1670515-02Medicaid
TX8J1473OtherBCBS
TX167051503Medicaid
TX8BR066OtherBCBS
TXP00232567Medicare PIN
TXP00738307Medicare PIN
TX1670515-02Medicaid
TX167051503Medicaid
TX8J1473OtherBCBS