Provider Demographics
NPI:1497062277
Name:GENTRY, JENNIE (COTA)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:GENTRY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 W. GRANDE BLVD
Mailing Address - Street 2:APT 111
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703
Mailing Address - Country:US
Mailing Address - Phone:817-433-0721
Mailing Address - Fax:
Practice Address - Street 1:1617 PARK PLACE AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1300
Practice Address - Country:US
Practice Address - Phone:817-921-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210567225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX149984001Medicaid
TX676535Medicare UPIN