Provider Demographics
NPI:1629142823
Name:WHEAT, JERRY DANIEL (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:DANIEL
Last Name:WHEAT
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 LINCOLN CT
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-8363
Mailing Address - Country:US
Mailing Address - Phone:972-691-2625
Mailing Address - Fax:
Practice Address - Street 1:3700 W BERRY
Practice Address - Street 2:LUPTON STADIUM
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76129-0001
Practice Address - Country:US
Practice Address - Phone:817-257-5156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX03292255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer