Basic Information
| Provider Information | |||||||||
| NPI: | 1093348567 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MYERS-MCCULLOUGH | ||||||||
| FirstName: | JILL | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 833 ARLINGTON DR | ||||||||
| Address2: | |||||||||
| City: | WOODWAY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767123203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543158967 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2125 S 61ST ST | ||||||||
| Address2: | |||||||||
| City: | TEMPLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765046823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543148580 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2020 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2057693 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.