Basic Information
| Provider Information | |||||||||
| NPI: | 1497062277 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | GENTRY | ||||||||
| FirstName: | JENNIE | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1505 W. GRANDE BLVD | ||||||||
| Address2: | APT 111 | ||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174330721 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1617 PARK PLACE AVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761101300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179215020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2010 | ||||||||
| LastUpdateDate: | 09/01/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 210567 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 149984001 | 05 | TX | MEDICAID |