Provider Demographics
NPI:1497950786
Name:CROSSLAND, JENNIFER SUSANN (MPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUSANN
Last Name:CROSSLAND
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 MIDWESTERN PKWY
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76302-2211
Mailing Address - Country:US
Mailing Address - Phone:940-322-0771
Mailing Address - Fax:940-766-4943
Practice Address - Street 1:1005 MIDWESTERN PKWY
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76302-2211
Practice Address - Country:US
Practice Address - Phone:940-322-0771
Practice Address - Fax:940-766-4943
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1128387225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1128387OtherLICENSE #
TX111408402Medicaid
TX1128387OtherHUMANA
TX111408402Medicaid