1487809059 NPI number — PERSEPHANIE JAYNE FREEMAN L.M.T.

Table of content: PERSEPHANIE JAYNE FREEMAN L.M.T. (NPI 1487809059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487809059 NPI number — PERSEPHANIE JAYNE FREEMAN L.M.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREEMAN
Provider First Name:
PERSEPHANIE
Provider Middle Name:
JAYNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.M.T.
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:
1487809059
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7616 FOX RIVER CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76120-3411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-457-2743
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1060 W PIPELINE RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
HURST
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76053-4732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-291-9014
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/24/2008

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: 225700000X , with the licence number:  MT046271 , 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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