Basic Information
| Provider Information | |||||||||
| NPI: | 1114408663 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FIFE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 LCR 654 | ||||||||
| Address2: | |||||||||
| City: | THORNTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 766872196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033882927 | ||||||||
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| Practice Location | |||||||||
| Address1: | 831 TEHUACANA | ||||||||
| Address2: | |||||||||
| City: | MEXIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2545623867 | ||||||||
| FaxNumber: | 2545627753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2018 | ||||||||
| LastUpdateDate: | 08/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2071543 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.