Provider Demographics
NPI:1568741031
Name:PUCKETT, JADE ISIS (PT)
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:ISIS
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6081 TRENT CT
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-6539
Mailing Address - Country:US
Mailing Address - Phone:832-260-8993
Mailing Address - Fax:832-426-0299
Practice Address - Street 1:6081 TRENT CT
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-6539
Practice Address - Country:US
Practice Address - Phone:832-260-8993
Practice Address - Fax:832-426-0299
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1185668225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1185668OtherPT LICENSE