Provider Demographics
NPI:1023624772
Name:WILLARD, JACI LEA (PT, DPT)
Entity type:Individual
Prefix:
First Name:JACI
Middle Name:LEA
Last Name:WILLARD
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PALOMINO LN
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:TX
Mailing Address - Zip Code:75009-4628
Mailing Address - Country:US
Mailing Address - Phone:214-232-7349
Mailing Address - Fax:
Practice Address - Street 1:5236 W UNIVERSITY DR STE 3500
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071-8122
Practice Address - Country:US
Practice Address - Phone:469-952-5082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1337035225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist