Provider Demographics
NPI:1679560726
Name:MIETUS, JENNIFER (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MIETUS
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 1:910 HILLS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-5232
Mailing Address - Country:US
Mailing Address - Phone:972-486-3115
Mailing Address - Fax:972-486-3115
Practice Address - Street 1:2301 IRA E WOODS AVE
Practice Address - Street 2:BUILDING B
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3926
Practice Address - Country:US
Practice Address - Phone:817-310-3737
Practice Address - Fax:817-310-3736
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1137222225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8B9356Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER