MEDICARE: JADE ISIS PUCKETT PT

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	225100000X	Physical Therapist	1185668	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1185668	OTHER	TX	PT LICENSE

General Provider Information

NPI Number	:	1568741031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JADE ISIS PUCKETT PT

Provider Business Mailing Address
First Line	:	6081 TRENT CT
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-6539
Country	:	US
Telephone Number	:	832-260-8993
Fax Number	:	832-426-0299

Provider Business Practice Location Address
First Line	:	6081 TRENT CT
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-6539
Country	:	US
Telephone Number	:	832-260-8993
Fax Number	:	832-426-0299

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

Provider Enumeration Date	:	08/15/2011
Last Update Date	:	08/15/2011

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