Healthcare Provider Details

I. General information

NPI: 1407077696
Provider Name (Legal Business Name): JPSHEALTH NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S MAIN ST
FORT WORTH TX
76104-4917
US

IV. Provider business mailing address

1500 S MAIN ST
FORT WORTH TX
76104-4917
US

V. Phone/Fax

Practice location:
  • Phone: 817-927-1395
  • Fax: 817-927-3603
Mailing address:
  • Phone: 817-927-1395
  • Fax: 817-927-3603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberD1758
License Number StateTX

VIII. Authorized Official

Name: DR. NELS KERMIT OLSON
Title or Position: PHYSICIAN
Credential:
Phone: 817-927-1395