Provider Demographics
NPI:1205485851
Name:JENSEN, LEILA MARIE (PTA, LMT)
Entity type:Individual
Prefix:
First Name:LEILA
Middle Name:MARIE
Last Name:JENSEN
Suffix:
Gender:F
Credentials:PTA, LMT
Other - Prefix:
Other - First Name:LEILA
Other - Middle Name:
Other - Last Name:MOURINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA, LMT
Mailing Address - Street 1:1318 KALLIE HILLS LN
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77386-3755
Mailing Address - Country:US
Mailing Address - Phone:281-757-7111
Mailing Address - Fax:
Practice Address - Street 1:14405 WALTERS RD STE 1017
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77014-1337
Practice Address - Country:US
Practice Address - Phone:281-781-8283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2150058225200000X
TXMT127712225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty