Provider Demographics
NPI:1457034910
Name:MANCILLA, JAY MAR SANTOS (PT)
Entity Type:Individual
Prefix:MR
First Name:JAY MAR
Middle Name:SANTOS
Last Name:MANCILLA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7423 BURNING TREE DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77036-5516
Mailing Address - Country:US
Mailing Address - Phone:832-594-7110
Mailing Address - Fax:
Practice Address - Street 1:7600 BEECHNUT ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-4302
Practice Address - Country:US
Practice Address - Phone:713-456-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1083897225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist