Provider Demographics
NPI:1053694752
Name:WELLS, JESSICA NICHOLE (DPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICHOLE
Last Name:WELLS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:305 NE LOOP 280; BUSINESS TOWER 1
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053
Mailing Address - Country:US
Mailing Address - Phone:817-292-8787
Mailing Address - Fax:817-789-6849
Practice Address - Street 1:1000 SAINT LOUIS AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3366
Practice Address - Country:US
Practice Address - Phone:817-921-5020
Practice Address - Fax:817-921-5022
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1206901225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist