1720411499 NPI number — MRS. JACQUELINE RENEE WINDLE PT

Table of content: MRS. JACQUELINE RENEE WINDLE PT (NPI 1720411499)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720411499 NPI number — MRS. JACQUELINE RENEE WINDLE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WINDLE
Provider First Name:
JACQUELINE
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HORNER
Provider Other First Name:
JACQUELINE
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720411499
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4621 W PARK BLVD
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75093
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-985-1776
Provider Business Mailing Address Fax Number:
972-985-6088

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4621 W PARK BLVD
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75093-2318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-985-1776
Provider Business Practice Location Address Fax Number:
972-985-6088
Provider Enumeration Date:
08/16/2013

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:  1234840 , 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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