Provider Demographics
NPI:1538822689
Name:JACK, TONSEL
Entity type:Individual
Prefix:
First Name:TONSEL
Middle Name:
Last Name:JACK
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 1:1301 E BARDIN RD UNIT 181801
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76096-4272
Mailing Address - Country:US
Mailing Address - Phone:866-488-4546
Mailing Address - Fax:178-210-6624
Practice Address - Street 1:1301 E BARDIN RD UNIT 181801
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76096-4272
Practice Address - Country:US
Practice Address - Phone:866-488-4546
Practice Address - Fax:178-210-6624
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-15
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX871002728OtherPEDORTHIST