Provider Demographics
NPI:1750832309
Name:HAWTHORNE, JEFFREY JR (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:HAWTHORNE
Suffix:JR
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 ROYAL CREST DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76140-2712
Mailing Address - Country:US
Mailing Address - Phone:214-235-1956
Mailing Address - Fax:
Practice Address - Street 1:5100 WILLIE ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76105-2860
Practice Address - Country:US
Practice Address - Phone:817-815-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT61822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer