Provider Demographics
NPI:1558040261
Name:NEWBOLD, JENNIFER DAWN (LMT, MTI)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:NEWBOLD
Suffix:
Gender:F
Credentials:LMT, MTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4945 WILLIAMS DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78633-2008
Mailing Address - Country:US
Mailing Address - Phone:512-509-2301
Mailing Address - Fax:
Practice Address - Street 1:4945 WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78633-2008
Practice Address - Country:US
Practice Address - Phone:512-509-2301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX132686225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist