Basic Information
| Provider Information | |||||||||
| NPI: | 1023746047 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHWARTZ | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | ANNETTE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RICHARDSON | ||||||||
| OtherFirstName: | JAQUELINE | ||||||||
| OtherMiddleName: | ANNETTE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4601 HARTFORD ST | ||||||||
| Address2: | |||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796054603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3257933400 | ||||||||
| FaxNumber: | 3257933587 | ||||||||
| Practice Location | |||||||||
| Address1: | 3001 S JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANGELO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 769045129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3252236300 | ||||||||
| FaxNumber: | 3257933587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2022 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1192118 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1192118 | 01 | TX | COMMERCIAL | OTHER | 1192118 | 05 | TX | MEDICAID |