Provider Demographics
NPI:1477259349
Name:LAND, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3924 POLAR BROOK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-7429
Mailing Address - Country:US
Mailing Address - Phone:432-770-0611
Mailing Address - Fax:
Practice Address - Street 1:140 PECAN ST
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-2215
Practice Address - Country:US
Practice Address - Phone:817-812-6393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT036094225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist