Provider Demographics
NPI:1407856644
Name:HENNESSEY, JAMIE (PT, MPT, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:HENNESSEY
Suffix:
Gender:F
Credentials:PT, MPT, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-1032
Mailing Address - Country:US
Mailing Address - Phone:512-509-7600
Mailing Address - Fax:
Practice Address - Street 1:300 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-1032
Practice Address - Country:US
Practice Address - Phone:512-509-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06562R225100000X
TX1146477225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4H0887876Medicare UPIN