Provider Demographics
NPI:1780019869
Name:BIVINS, JAN LEE (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:MRS
First Name:JAN
Middle Name:LEE
Last Name:BIVINS
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5514 W MILES ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763-9000
Mailing Address - Country:US
Mailing Address - Phone:432-352-4570
Mailing Address - Fax:
Practice Address - Street 1:322 N TEXAS AVE STE 2
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5184
Practice Address - Country:US
Practice Address - Phone:432-352-4570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT027544225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist