Provider Demographics
NPI:1255158556
Name:DOUGLAS, JAMAL LARONNE (LMT CLT)
Entity type:Individual
Prefix:MR
First Name:JAMAL
Middle Name:LARONNE
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:LMT CLT
Other - Prefix:MR
Other - First Name:MUSTAPHA
Other - Middle Name:
Other - Last Name:SAVAGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT CLT
Mailing Address - Street 1:2173 SOUTHERN PLACE
Mailing Address - Street 2:UNIT A
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006
Mailing Address - Country:US
Mailing Address - Phone:469-592-1011
Mailing Address - Fax:
Practice Address - Street 1:2757 E SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092
Practice Address - Country:US
Practice Address - Phone:682-688-5534
Practice Address - Fax:682-688-5549
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT139208225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist