Individual
JENNIE GENTRY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
COTA
Contact information
Practice address
1617 PARK PLACE AVE, SUITE 110, FORT WORTH, TX 76110-1300
(817) 921-5020
Mailing address
1505 W. GRANDE BLVD, APT 111, TYLER, TX 75703
(817) 433-0721
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
210567
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
149984001
—
TX
Enumeration date
09/01/2010
Last updated
09/01/2010
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