Provider Demographics
NPI:1316360019
Name:URSERY, JACK TRAVIS (MS, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:TRAVIS
Last Name:URSERY
Suffix:
Gender:M
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 7TH ST
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77414-4840
Mailing Address - Country:US
Mailing Address - Phone:979-245-5771
Mailing Address - Fax:979-245-2321
Practice Address - Street 1:400 7TH ST
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:TX
Practice Address - Zip Code:77414-4840
Practice Address - Country:US
Practice Address - Phone:979-245-5771
Practice Address - Fax:979-245-2321
Is Sole Proprietor?:No
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT53392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer