Basic Information
Provider Information | |||||||||
NPI: | 1114546397 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THOMAS | ||||||||
FirstName: | JESSIE | ||||||||
MiddleName: | DELL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT, DPT, CSCS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2650 | ||||||||
Address2: |   | ||||||||
City: | COPPELL | ||||||||
State: | TX | ||||||||
PostalCode: | 750198607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9727242400 | ||||||||
FaxNumber: | 9727242495 | ||||||||
Practice Location | |||||||||
Address1: | 12520 WILLOW SPRINGS RD STE 104 | ||||||||
Address2: |   | ||||||||
City: | HASLET | ||||||||
State: | TX | ||||||||
PostalCode: | 760523584 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8172106196 | ||||||||
FaxNumber: | 8177829303 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/08/2020 | ||||||||
LastUpdateDate: | 07/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1322780 | TX | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225100000X | CP011077T | MO | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.