Provider Demographics
NPI:1861050551
Name:WLASIUK, JENNIFER (DPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WLASIUK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3824 S CARRIER PKWY STE 470
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-6645
Mailing Address - Country:US
Mailing Address - Phone:972-262-9972
Mailing Address - Fax:972-262-9986
Practice Address - Street 1:2851 MATLOCK RD STE 600
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5039
Practice Address - Country:US
Practice Address - Phone:817-473-6246
Practice Address - Fax:817-473-2014
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO296504225100000X
CA2965042251S0007X, 2251X0800X
TX1347217225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic