Provider Demographics
NPI:1255811063
Name:SUTHERLAND, JENNIFER (PTA,CLT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:PTA,CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 NUGENT DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5125
Mailing Address - Country:US
Mailing Address - Phone:619-246-6779
Mailing Address - Fax:
Practice Address - Street 1:724 W. RENDON CROWLEY RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76036
Practice Address - Country:US
Practice Address - Phone:817-297-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2058517225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant