Provider Demographics
NPI:1518331263
Name:DAVIS, JACINDA (LMT)
Entity Type:Individual
Prefix:
First Name:JACINDA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 ELKFORD LN
Mailing Address - Street 2:
Mailing Address - City:JUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:76247-5782
Mailing Address - Country:US
Mailing Address - Phone:817-823-0218
Mailing Address - Fax:
Practice Address - Street 1:1240 SOUTHRIDGE CT
Practice Address - Street 2:SUITE 101
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-4306
Practice Address - Country:US
Practice Address - Phone:817-823-0218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXLMT111900172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist