Provider Demographics
NPI:1174934822
Name:DEVAUGHN, JARVIS (OT)
Entity type:Individual
Prefix:MR
First Name:JARVIS
Middle Name:
Last Name:DEVAUGHN
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4423 SHADOWDALE DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77041-8718
Mailing Address - Country:US
Mailing Address - Phone:713-466-6872
Mailing Address - Fax:713-466-9547
Practice Address - Street 1:4423 SHADOWDALE DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77041-8718
Practice Address - Country:US
Practice Address - Phone:713-466-6872
Practice Address - Fax:713-466-9547
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116054225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX116054OtherOT LICENSE NUMBER