Provider Demographics
NPI:1407330798
Name:JENKINS, THOMAS EDELL (PTA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:EDELL
Last Name:JENKINS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1042 COUNTY ROAD 1124
Mailing Address - Street 2:
Mailing Address - City:DAINGERFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:75638-7348
Mailing Address - Country:US
Mailing Address - Phone:903-452-4272
Mailing Address - Fax:
Practice Address - Street 1:1042 COUNTY ROAD 1124
Practice Address - Street 2:
Practice Address - City:DAINGERFIELD
Practice Address - State:TX
Practice Address - Zip Code:75638-7348
Practice Address - Country:US
Practice Address - Phone:903-452-4272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2095450225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2095450Medicaid