Provider Demographics
NPI:1407004443
Name:GARNER, JACQUELYN A (OT)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:A
Last Name:GARNER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2603
Mailing Address - Street 2:HTN CLIENT ACCOUNTING
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76113-2603
Mailing Address - Country:US
Mailing Address - Phone:817-569-4396
Mailing Address - Fax:817-569-4517
Practice Address - Street 1:3840 HULEN ST
Practice Address - Street 2:HTN CLIENT ACCOUNTING
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7277
Practice Address - Country:US
Practice Address - Phone:817-569-4396
Practice Address - Fax:817-569-4517
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109480225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX194616201Medicaid
TX8T5168OtherBCBS