Provider Demographics
NPI:1043775992
Name:MATHEWS, JERRIL (OTR, MOT)
Entity Type:Individual
Prefix:
First Name:JERRIL
Middle Name:
Last Name:MATHEWS
Suffix:
Gender:M
Credentials:OTR, MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2129 CORAL CT
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75060-7343
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2101 W NORTHGATE DR
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062
Practice Address - Country:US
Practice Address - Phone:972-255-4460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-05
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19232225X00000X
TX118821225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist