MEDICARE: MRS. JAQUETTA L HALEY 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	2039493	TX

General Provider Information

NPI Number	:	1568609162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JAQUETTA L HALEY PTA

Provider Business Mailing Address
First Line	:	3124 PRIMROSE DR
Second Line	:
City	:	ABILENE
State	:	TX
Zip	:	79606-3327
Country	:	US
Telephone Number	:	325-793-1636
Fax Number	:

Provider Business Practice Location Address
First Line	:	2722 OLD ANSON RD
Second Line	:
City	:	ABILENE
State	:	TX
Zip	:	79603-1834
Country	:	US
Telephone Number	:	325-676-1677
Fax Number	:

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

Provider Enumeration Date	:	01/19/2009
Last Update Date	:	01/19/2009

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