Healthcare Provider Details

I. General information

NPI: 1104402718
Provider Name (Legal Business Name): PATRICIA KAYE JAYNES ATC, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 05/19/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11210 US 290, STE A230
AUSTIN TX
78631
US

IV. Provider business mailing address

13062 US 290 STE 100
AUSTIN TX
78631
US

V. Phone/Fax

Practice location:
  • Phone: 512-362-8865
  • Fax:
Mailing address:
  • Phone: 512-362-8865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT5816
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT132694
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: