MEDICARE: JOLENE SUE HAWORTH OTR

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	225X00000X	Occupational Therapist	112306	TX

General Provider Information

NPI Number	:	1750562468
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOLENE SUE HAWORTH OTR

Provider Business Mailing Address
First Line	:	3400 ROGER BROOKE DR
Second Line	:	SUITE B
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-6315
Country	:	US
Telephone Number	:	210-916-1440
Fax Number	:

Provider Business Practice Location Address
First Line	:	3400 ROGER BROOKE DR
Second Line	:	SUITE B
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-6315
Country	:	US
Telephone Number	:	210-916-1440
Fax Number	:

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

Provider Enumeration Date	:	11/21/2007
Last Update Date	:	11/21/2007

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