Healthcare Provider Details

I. General information

NPI: 1215248265
Provider Name (Legal Business Name): JPS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 07/21/2022
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

3909 WARWICK DR
NORMAN OK
73072-3232
US

V. Phone/Fax

Practice location:
  • Phone: 817-921-3431
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number StateTX

VIII. Authorized Official

Name: NATHAN STICKNEY
Title or Position: DPM
Credential:
Phone: 405-361-0924