Provider Demographics
NPI:1447882923
Name:GUBERNATH, JESSICA (LVN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GUBERNATH
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 8TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-6818
Mailing Address - Country:US
Mailing Address - Phone:940-761-9986
Mailing Address - Fax:
Practice Address - Street 1:4345 CUNNINGHAM DR
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2609
Practice Address - Country:US
Practice Address - Phone:940-867-3309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX312163164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse