Provider Demographics
NPI:1477433811
Name:FOMBAD, JERRY
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:FOMBAD
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 1:7803 BARN SWALLOW DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75036-5259
Mailing Address - Country:US
Mailing Address - Phone:678-464-5790
Mailing Address - Fax:
Practice Address - Street 1:7803 BARN SWALLOW DR
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75036-5259
Practice Address - Country:US
Practice Address - Phone:678-464-5790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-05
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213095224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant