Provider Demographics
NPI:1689974065
Name:JACK, ROSELYN ADDY (BSC,CFTS)
Entity Type:Individual
Prefix:MS
First Name:ROSELYN
Middle Name:ADDY
Last Name:JACK
Suffix:
Gender:F
Credentials:BSC,CFTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:982 NORTH COOPER STREET
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76011
Mailing Address - Country:US
Mailing Address - Phone:817-597-7137
Mailing Address - Fax:817-299-0394
Practice Address - Street 1:982 NORTH COOPER STREET
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011
Practice Address - Country:US
Practice Address - Phone:817-597-7137
Practice Address - Fax:817-299-0394
Is Sole Proprietor?:No
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor