Provider Demographics
NPI:1932110871
Name:FAGLIE, JEANETTE ELAINE (LPTA)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:ELAINE
Last Name:FAGLIE
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 STAGECOACH TRL
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-3222
Mailing Address - Country:US
Mailing Address - Phone:254-743-2250
Mailing Address - Fax:254-743-0313
Practice Address - Street 1:1901 S 1ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-7451
Practice Address - Country:US
Practice Address - Phone:254-743-2250
Practice Address - Fax:254-743-0313
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2015715225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant