Provider Demographics
NPI:1205067568
Name:TER MOLEN, JANNA LEIGH (PT)
Entity type:Individual
Prefix:
First Name:JANNA
Middle Name:LEIGH
Last Name:TER MOLEN
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 1:6080 SOUTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76109-3912
Mailing Address - Country:US
Mailing Address - Phone:817-731-9331
Mailing Address - Fax:817-731-9882
Practice Address - Street 1:6080 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76109-3912
Practice Address - Country:US
Practice Address - Phone:817-731-9331
Practice Address - Fax:817-731-9882
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-05
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2073419225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant