Provider Demographics
NPI:1922719517
Name:WILLIS, JARVIS
Entity type:Individual
Prefix:
First Name:JARVIS
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6625 N MAIN ST UNIT G
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77009-1066
Mailing Address - Country:US
Mailing Address - Phone:205-874-5335
Mailing Address - Fax:
Practice Address - Street 1:6625 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77009-1063
Practice Address - Country:US
Practice Address - Phone:205-874-5335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-06
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X
TX2168262225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No171W00000XOther Service ProvidersContractor