Provider Demographics
NPI:1225392988
Name:WALLIN, JENNIFER MICHELLE (PTA)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:WALLIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:MICHELLE
Other - Last Name:MEEKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:105 ARBOR DR
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:TX
Mailing Address - Zip Code:77536-6211
Mailing Address - Country:US
Mailing Address - Phone:832-528-2053
Mailing Address - Fax:
Practice Address - Street 1:105 ARBOR DR
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:TX
Practice Address - Zip Code:77536-6211
Practice Address - Country:US
Practice Address - Phone:832-528-2053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2061210225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant