Healthcare Provider Details

I. General information

NPI: 1174934822
Provider Name (Legal Business Name): JARVIS DEVAUGHN OT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2014
Last Update Date: 05/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4423 SHADOWDALE DR
HOUSTON TX
77041-8718
US

IV. Provider business mailing address

4423 SHADOWDALE DR
HOUSTON TX
77041-8718
US

V. Phone/Fax

Practice location:
  • Phone: 713-466-6872
  • Fax: 713-466-9547
Mailing address:
  • Phone: 713-466-6872
  • Fax: 713-466-9547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number116054
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: