Healthcare Provider Details

I. General information

NPI: 1639587124
Provider Name (Legal Business Name): JANETTE MEJIA P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 07/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1318 MEMORIAL DR
BRYAN TX
77802-5215
US

IV. Provider business mailing address

1318 MEMORIAL DR
BRYAN TX
77802-5215
US

V. Phone/Fax

Practice location:
  • Phone: 979-776-2872
  • Fax: 979-776-1456
Mailing address:
  • Phone: 979-776-2872
  • Fax: 979-776-1456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2103935
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: