Provider Demographics
NPI:1891146825
Name:PAREDES, JACQUELINE (PTA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:PAREDES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6155 ECKHERT RD APT 15201
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-3192
Mailing Address - Country:US
Mailing Address - Phone:432-349-4376
Mailing Address - Fax:
Practice Address - Street 1:801 W ANN ARBOR TRL
Practice Address - Street 2:SUITE 200
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1694
Practice Address - Country:US
Practice Address - Phone:734-468-0397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2030302225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant