Basic Information
| Provider Information | |||||||||
| NPI: | 1073127171 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAN | ||||||||
| FirstName: | JENNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4100 N SAM HOUSTON PKWY W STE 240 | ||||||||
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| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770861466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8329687155 | ||||||||
| FaxNumber: | 7133839795 | ||||||||
| Practice Location | |||||||||
| Address1: | 4100 N SAM HOUSTON PKWY W STE 240 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770861466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8329687155 | ||||||||
| FaxNumber: | 7133839795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2020 | ||||||||
| LastUpdateDate: | 09/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1329407 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.