Healthcare Provider Details

I. General information

NPI: 1437639226
Provider Name (Legal Business Name): MARICEL ANTONIO JENNINGS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2018
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3443 N MACARTHUR BLVD
IRVING TX
75062-4411
US

IV. Provider business mailing address

214 KNAPFORD STA
EULESS TX
76040-3212
US

V. Phone/Fax

Practice location:
  • Phone: 469-586-4424
  • Fax:
Mailing address:
  • Phone: 972-730-1002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number1214223
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: