Provider Demographics
NPI:1760099212
Name:DONOHOO, JERRED SHANE (PTA)
Entity Type:Individual
Prefix:MR
First Name:JERRED
Middle Name:SHANE
Last Name:DONOHOO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3818 DECKER DR
Mailing Address - Street 2:
Mailing Address - City:BAYTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:77520-1662
Mailing Address - Country:US
Mailing Address - Phone:281-424-7557
Mailing Address - Fax:281-424-7567
Practice Address - Street 1:9235 N HIGHWAY 146
Practice Address - Street 2:
Practice Address - City:MONT BELVIEU
Practice Address - State:TX
Practice Address - Zip Code:77523-7876
Practice Address - Country:US
Practice Address - Phone:832-307-7966
Practice Address - Fax:832-307-7964
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2156850225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant