Healthcare Provider Details

I. General information

NPI: 1184664740
Provider Name (Legal Business Name): JANE JOHNSON O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 02/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 N BEDELL AVE #B
DEL RIO TX
78840-8007
US

IV. Provider business mailing address

2201 N BEDELL AVE #B
DEL RIO TX
78840-8007
US

V. Phone/Fax

Practice location:
  • Phone: 830-774-1556
  • Fax: 830-774-6150
Mailing address:
  • Phone: 830-774-1556
  • Fax: 830-774-6150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT110488
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: