MEDICARE: FREEFORM WELLNESS PLLC

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	208100000X	Physical Medicine & Rehabilitation Physician

General Provider Information

NPI Number	:	1689185803
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FREEFORM WELLNESS PLLC

Provider Business Mailing Address
First Line	:	4525 HERITAGE TRACE PKWY STE 101
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-8908
Country	:	US
Telephone Number	:	817-431-5100
Fax Number	:

Provider Business Practice Location Address
First Line	:	4525 HERITAGE TRACE PKWY STE 101
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-8908
Country	:	US
Telephone Number	:	817-431-5100
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JESSE JACOBS
Credential	:
Telephone Number	:	817-431-5100

Provider Enumeration Date	:	10/15/2017
Last Update Date	:	10/15/2017

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Directions to “FREEFORM WELLNESS PLLC ” Practice Location

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