Provider Demographics
NPI:1710484548
Name:JELICIC, JANE
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:JELICIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 AIRPORT FWY STE 150
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022-6050
Mailing Address - Country:US
Mailing Address - Phone:817-508-0030
Mailing Address - Fax:877-774-5457
Practice Address - Street 1:6243 BENTWOOD TRL
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-5151
Practice Address - Country:US
Practice Address - Phone:214-793-8184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14673251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health