Provider Demographics
NPI:1700065125
Name:ROMANS, JERRY
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:ROMANS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5012 TRINITY LANDING DR W
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-3736
Mailing Address - Country:US
Mailing Address - Phone:817-701-8642
Mailing Address - Fax:
Practice Address - Street 1:5012 TRINITY LANDING DR W
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3736
Practice Address - Country:US
Practice Address - Phone:817-701-8642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities