Healthcare Provider Details

I. General information

NPI: 1285912931
Provider Name (Legal Business Name): JPS PHYSICIAN GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1617 HEMPHILL ST
FORT WORTH TX
76104-4709
US

IV. Provider business mailing address

7148 TRAIL LAKE DR
FORT WORTH TX
76123-1969
US

V. Phone/Fax

Practice location:
  • Phone: 817-920-6245
  • Fax:
Mailing address:
  • Phone: 817-920-6245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM JOHNSON
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 817-920-3887