Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 1162656 | TX |
Y | 2251P0200X | Physical Therapist - Pediatrics | 1162656 | TX |
NPI | 1043787500 |
---|---|
Provider Name | Jaymes Mennel |
First Address | Montgomery, TX 77384 |
Second Address | Montgomery, TX 77384 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/11/2018 |
Last Update Date | 01/11/2018 |