Healthcare Provider Details

I. General information

NPI: 1477759504
Provider Name (Legal Business Name): JACQULINE O'NEAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 KARI LN APT 1722
GREENVILLE TX
75402-7200
US

IV. Provider business mailing address

4006 SHADY OAK DR
OOLTEWAH TN
37363-7012
US

V. Phone/Fax

Practice location:
  • Phone: 903-408-1886
  • Fax:
Mailing address:
  • Phone: 423-903-5918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2061750
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: