Provider Demographics
NPI:1093348567
Name:MYERS-MCCULLOUGH, JILL (PTA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:MYERS-MCCULLOUGH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 ARLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:WOODWAY
Mailing Address - State:TX
Mailing Address - Zip Code:76712-3203
Mailing Address - Country:US
Mailing Address - Phone:254-315-8967
Mailing Address - Fax:
Practice Address - Street 1:2125 S 61ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-6823
Practice Address - Country:US
Practice Address - Phone:254-314-8580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2057693225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant