Provider Demographics
NPI:1336920305
Name:HERNANDEZ, JOSE (LMT LE CI)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:LMT LE CI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 STONE CHAPEL WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-7304
Mailing Address - Country:US
Mailing Address - Phone:817-584-0121
Mailing Address - Fax:
Practice Address - Street 1:908 STONE CHAPEL WAY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-7304
Practice Address - Country:US
Practice Address - Phone:817-584-0121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT123097225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist