Healthcare Provider Details

I. General information

NPI: 1932879905
Provider Name (Legal Business Name): JENNIFER REVELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2021
Last Update Date: 09/20/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13195 BURNET RD SUITE 204
AUSTIN TX
78728
US

IV. Provider business mailing address

13195 BURNET RD SUITE 204
AUSTIN TX
78728
US

V. Phone/Fax

Practice location:
  • Phone: 817-505-2575
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2159427
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: