Provider Demographics
NPI:1831797166
Name:HENRY, JENNA MARIE
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:HENRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8280 MEADOW RD APT 6411
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-3793
Mailing Address - Country:US
Mailing Address - Phone:949-294-8104
Mailing Address - Fax:
Practice Address - Street 1:205 S MAIN ST STE 1010
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:TX
Practice Address - Zip Code:75154-4664
Practice Address - Country:US
Practice Address - Phone:469-917-0805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1333771225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist