=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457018780
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOLINA C FRYE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2021
-----------------------------------------------------
Last Update Date | 11/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 COUNTRY BROOK DR
-----------------------------------------------------
City | KELLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76248-2125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-688-9868
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1306 SPEEDWAY DR
-----------------------------------------------------
City | RHOME
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76078-4843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-331-4946
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2153570
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------