Provider Demographics
NPI:1669557377
Name:THOMAS, JEANINE ROSE (PT)
Entity type:Individual
Prefix:MRS
First Name:JEANINE
Middle Name:ROSE
Last Name:THOMAS
Suffix:
Gender:F
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:PO BOX 475
Mailing Address - Street 2:
Mailing Address - City:CRANDALL
Mailing Address - State:TX
Mailing Address - Zip Code:75114-0475
Mailing Address - Country:US
Mailing Address - Phone:972-427-3704
Mailing Address - Fax:
Practice Address - Street 1:789 JUSTIN RD
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-4840
Practice Address - Country:US
Practice Address - Phone:972-771-5731
Practice Address - Fax:972-771-5786
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1091163225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T3238OtherBLUE CROSS BLUE SHIELD
TX0094LVOtherBLUE CROSS BLUE SHIELD