Provider Demographics
NPI:1033998612
Name:THOENNISSEN, JENNIFER M (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:THOENNISSEN
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 1:1533 MARICOPA RD
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34287-4123
Mailing Address - Country:US
Mailing Address - Phone:941-468-7078
Mailing Address - Fax:
Practice Address - Street 1:14580 TAMIAMI TRL # DE
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34287-2708
Practice Address - Country:US
Practice Address - Phone:941-200-2570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA23456225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant