MEDICARE: MR. JARED N RENEAU PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2071468	TX

General Provider Information

NPI Number	:	1508149550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JARED N RENEAU PTA

Provider Business Mailing Address
First Line	:	8440 N SAM HOUSTON PKWY E APT 717
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77396-2969
Country	:	US
Telephone Number	:	936-676-9614
Fax Number	:

Provider Business Practice Location Address
First Line	:	8440 N SAM HOUSTON PKWY E APT 717
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77396-2969
Country	:	US
Telephone Number	:	936-676-9614
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2011
Last Update Date	:	09/26/2011

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