Provider Demographics
NPI:1104225515
Name:WALLINE, JENNIFER (DPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WALLINE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:BERLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:4040 BRYCE LN
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75077-7038
Mailing Address - Country:US
Mailing Address - Phone:940-241-1215
Mailing Address - Fax:940-455-2041
Practice Address - Street 1:4040 BRYCE LN
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75077-7038
Practice Address - Country:US
Practice Address - Phone:940-241-1215
Practice Address - Fax:940-455-2041
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10070225100000X
TX1353422225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ014271Medicaid
TN103I655304Medicare PIN