Provider Demographics
NPI:1669989471
Name:PETERS, JAMES GLENN JR (LMT)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:GLENN
Last Name:PETERS
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6320 LBJ FWY STE 122
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-6428
Mailing Address - Country:US
Mailing Address - Phone:214-310-0414
Mailing Address - Fax:
Practice Address - Street 1:6320 LBJ FWY STE 122
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6428
Practice Address - Country:US
Practice Address - Phone:214-310-0414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT116421225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist