Healthcare Provider Details

I. General information

NPI: 1740826411
Provider Name (Legal Business Name): JESSICA MAE YEAGER PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2019
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 VILLA CREEK DR
DALLAS TX
75234-7324
US

IV. Provider business mailing address

4332 MERRELL RD
DALLAS TX
75229-5438
US

V. Phone/Fax

Practice location:
  • Phone: 817-733-7117
  • Fax:
Mailing address:
  • Phone: 817-733-7117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1272107
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: