Provider Demographics
NPI:1033775119
Name:RAINWATER, JENNIFER MARIA (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIA
Last Name:RAINWATER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2445 E ALPINE AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-1502
Mailing Address - Country:US
Mailing Address - Phone:619-244-4726
Mailing Address - Fax:
Practice Address - Street 1:2012 W SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85120-7305
Practice Address - Country:US
Practice Address - Phone:480-983-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12858A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant