Provider Demographics
NPI:1114408663
Name:FIFE, JENNIFER ELAINE (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELAINE
Last Name:FIFE
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 1:2300 LCR 654
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:TX
Mailing Address - Zip Code:76687-2196
Mailing Address - Country:US
Mailing Address - Phone:903-388-2927
Mailing Address - Fax:
Practice Address - Street 1:831 TEHUACANA
Practice Address - Street 2:
Practice Address - City:MEXIA
Practice Address - State:TX
Practice Address - Zip Code:76667
Practice Address - Country:US
Practice Address - Phone:254-562-3867
Practice Address - Fax:254-562-7753
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2071543225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant