Provider Demographics
NPI:1740542083
Name:RADLE, JENNICA VAUGHAN (PTA)
Entity type:Individual
Prefix:
First Name:JENNICA
Middle Name:VAUGHAN
Last Name:RADLE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 NE LOOP 410 STE 612
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-5866
Mailing Address - Country:US
Mailing Address - Phone:801-721-9170
Mailing Address - Fax:
Practice Address - Street 1:85 NE LOOP 410 STE 612
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-5866
Practice Address - Country:US
Practice Address - Phone:210-494-2343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2086140225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2086140OtherPHYSICAL THERAPY