Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 1255271 | TX |
N | 225700000X | Massage Therapist | MT048004 | TX |
NPI | 1003293143 |
---|---|
Provider Name | Jennifer Theis |
First Address | Carrollton, TX 75007-4311 |
Second Address | Carrollton, TX 75007-4311 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/04/2015 |
Last Update Date | 28/04/2015 |