Provider Demographics
NPI:1134907553
Name:VEINE, JEREMY (PTA)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:VEINE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 E STATE HIGHWAY 114 STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-5251
Mailing Address - Country:US
Mailing Address - Phone:817-502-4211
Mailing Address - Fax:817-502-7412
Practice Address - Street 1:9525 N BEACH ST STE 413
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6438
Practice Address - Country:US
Practice Address - Phone:817-502-7411
Practice Address - Fax:817-502-7412
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2148492225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant