Healthcare Provider Details

I. General information

NPI: 1275260101
Provider Name (Legal Business Name): JAQUITA WEHRLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1341 W MOCKINGBIRD LN SUITE 600W-#30
DALLAS TX
75247
US

IV. Provider business mailing address

2770 BARDIN RD APT 5304
GRAND PRAIRIE TX
75052-7300
US

V. Phone/Fax

Practice location:
  • Phone: 972-358-7206
  • Fax:
Mailing address:
  • Phone: 972-358-7206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: