Provider Demographics
NPI:1538792254
Name:JUAREZ, JACQUELYN EILEEN (PTA)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:EILEEN
Last Name:JUAREZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:JACQUELYN
Other - Middle Name:EILEEN
Other - Last Name:JUAREZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:JACKIE
Mailing Address - Street 1:2500 STATE HIGHWAY 121 APT 323
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76039-6008
Mailing Address - Country:US
Mailing Address - Phone:940-366-9486
Mailing Address - Fax:
Practice Address - Street 1:2500 STATE HIGHWAY 121 APT 323
Practice Address - Street 2:
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76039-6008
Practice Address - Country:US
Practice Address - Phone:940-366-9486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2152244225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant