Provider Demographics
NPI:1215478938
Name:MAHAN, JILLIAN (PT, DPT)
Entity type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:
Last Name:MAHAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 COUNTY ROAD 412
Mailing Address - Street 2:
Mailing Address - City:GLEN ROSE
Mailing Address - State:TX
Mailing Address - Zip Code:76043-6000
Mailing Address - Country:US
Mailing Address - Phone:832-247-2499
Mailing Address - Fax:
Practice Address - Street 1:1005 NE BIG BEND TRL UNIT 7
Practice Address - Street 2:
Practice Address - City:GLEN ROSE
Practice Address - State:TX
Practice Address - Zip Code:76043-4943
Practice Address - Country:US
Practice Address - Phone:254-897-3176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-14
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1188449225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist