=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962929588
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J&J PHYSICAL THERAPY AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2017
-----------------------------------------------------
Last Update Date | 06/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 280 COMMERCE ST STE 115
-----------------------------------------------------
City | SOUTHLAKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-912-1420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 280 COMMERCE ST
-----------------------------------------------------
City | SOUTHLAKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76092-9100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-912-1420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JENNIFER WELLS MCCAULEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-912-1420
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------