Provider Demographics
NPI:1154700474
Name:SHINE, JADE (OT)
Entity type:Individual
Prefix:MS
First Name:JADE
Middle Name:
Last Name:SHINE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 NE LOOP 820
Mailing Address - Street 2:BUSINESS TOWER 1, SUITE 200
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-7209
Mailing Address - Country:US
Mailing Address - Phone:817-292-8787
Mailing Address - Fax:817-789-6849
Practice Address - Street 1:4828 LOOP CENTRAL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77081-2212
Practice Address - Country:US
Practice Address - Phone:713-979-3800
Practice Address - Fax:713-979-3806
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-19
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX187053225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist