Healthcare Provider Details

I. General information

NPI: 1659146769
Provider Name (Legal Business Name): JERROD MELENDEZ PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2023
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 ALSTON AVE STE 120
FORT WORTH TX
76104-4622
US

IV. Provider business mailing address

448 FUENTE
IRVING TX
75039-3408
US

V. Phone/Fax

Practice location:
  • Phone: 817-332-0660
  • Fax:
Mailing address:
  • Phone: 940-642-2966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2170335
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: