Provider Demographics
NPI:1104381649
Name:GRULLON, JAILEEN
Entity Type:Individual
Prefix:
First Name:JAILEEN
Middle Name:
Last Name:GRULLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9638 BEVERLYHILL ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063
Mailing Address - Country:US
Mailing Address - Phone:713-857-5903
Mailing Address - Fax:
Practice Address - Street 1:9638 BEVERLYHILL STREET
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77063
Practice Address - Country:US
Practice Address - Phone:713-857-5903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2126732225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant