Provider Demographics
NPI:1508288564
Name:THOMASSEN, JELICA (PTA)
Entity Type:Individual
Prefix:
First Name:JELICA
Middle Name:
Last Name:THOMASSEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 HOLLEMAN DR. E #832
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840
Mailing Address - Country:US
Mailing Address - Phone:941-544-2334
Mailing Address - Fax:
Practice Address - Street 1:301 HOLLEMAN DR E APT 832
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-7048
Practice Address - Country:US
Practice Address - Phone:941-544-2334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2099683225200000X
FL24097225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant