1942459953 NPI number — MRS. JESSICA JUTTE BERTRAM PT, DPT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942459953 NPI number — MRS. JESSICA JUTTE BERTRAM PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERTRAM
Provider First Name:
JESSICA
Provider Middle Name:
JUTTE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942459953
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1643 LANCASTER DR.
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
GRAPEVINE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-329-2524
Provider Business Mailing Address Fax Number:
817-329-2685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1643 LANCASTER DR.
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
GRAPEVINE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-329-2524
Provider Business Practice Location Address Fax Number:
817-329-2685
Provider Enumeration Date:
09/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1167472 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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