Basic Information
| Provider Information | |||||||||
| NPI: | 1477030195 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAWSON | ||||||||
| FirstName: | JACIE | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TARNO | ||||||||
| OtherFirstName: | JACIE | ||||||||
| OtherMiddleName: | DAWN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1136 E GRANDE BLVD | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757033982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035925601 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 921 SHILOH RD STE C120 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757031407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9039392800 | ||||||||
| FaxNumber: | 8663864531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2018 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1271607 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.