Provider Demographics
NPI:1962646463
Name:WILLINGHAM, JENNIE L (PT)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:L
Last Name:WILLINGHAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9050 N CAPITAL OF TEXAS HWY
Mailing Address - Street 2:BUILDING 3, SUITE 180
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-7268
Mailing Address - Country:US
Mailing Address - Phone:512-637-1550
Mailing Address - Fax:
Practice Address - Street 1:9050 N CAPITAL OF TEXAS HWY
Practice Address - Street 2:BUILDING 3, SUITE 180
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-7268
Practice Address - Country:US
Practice Address - Phone:512-637-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1125383225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist