MEDICARE: JACLYN HUMPHREY 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	2045680	TX

General Provider Information

NPI Number	:	1912670944
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYN HUMPHREY PTA

Provider Business Mailing Address
First Line	:	2611 SW 46TH AVE
Second Line	:
City	:	AMARILLO
State	:	TX
Zip	:	79110-1735
Country	:	US
Telephone Number	:	806-355-6517
Fax Number	:

Provider Business Practice Location Address
First Line	:	2611 SW 46TH AVE
Second Line	:
City	:	AMARILLO
State	:	TX
Zip	:	79110-1735
Country	:	US
Telephone Number	:	806-355-6517
Fax Number	:

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

Provider Enumeration Date	:	07/27/2021
Last Update Date	:	07/27/2021

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