MEDICARE: JEREMY VEINE PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2148492	TX

General Provider Information

NPI Number	:	1134907553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY VEINE PTA

Provider Business Mailing Address
First Line	:	1110 E STATE HIGHWAY 114 STE 100
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-5251
Country	:	US
Telephone Number	:	817-502-4211
Fax Number	:	817-502-7412

Provider Business Practice Location Address
First Line	:	9525 N BEACH ST STE 413
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-6438
Country	:	US
Telephone Number	:	817-502-7411
Fax Number	:	817-502-7412

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2023
Last Update Date	:	09/18/2023

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Directions to “ JEREMY VEINE PTA” Practice Location

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