Provider Demographics
NPI:1255831137
Name:MEDLOCK, JENNA (PT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:MEDLOCK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 UPPER BALCONES RD
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-8546
Mailing Address - Country:US
Mailing Address - Phone:210-360-1662
Mailing Address - Fax:
Practice Address - Street 1:12952 BANDERA RD STE 107
Practice Address - Street 2:
Practice Address - City:HELOTES
Practice Address - State:TX
Practice Address - Zip Code:78023-4733
Practice Address - Country:US
Practice Address - Phone:210-372-9600
Practice Address - Fax:210-392-9923
Is Sole Proprietor?:No
Enumeration Date:2018-02-16
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1271650225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist