Healthcare Provider Details

I. General information

NPI: 1689974065
Provider Name (Legal Business Name): ROSELYN ADDY JACK BSC,CFTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2010
Last Update Date: 11/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

982 NORTH COOPER STREET
ARLINGTON TX
76011
US

IV. Provider business mailing address

982 NORTH COOPER STREET
ARLINGTON TX
76011
US

V. Phone/Fax

Practice location:
  • Phone: 817-597-7137
  • Fax: 817-299-0394
Mailing address:
  • Phone: 817-597-7137
  • Fax: 817-299-0394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: