Provider Demographics
NPI:1306574843
Name:DAVIS, JADE (LMT)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:JADE
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:15905 BENT TREE FOREST CIR APT 1062
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-7052
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1807 N GRAVES ST
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75069-3423
Practice Address - Country:US
Practice Address - Phone:214-428-5752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT129868225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMT129868OtherTDLR