Provider Demographics
NPI:1043476286
Name:BRADY, JENNIFER R (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:BRADY
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 1:5940 SHAKERTOWN DR NW
Mailing Address - Street 2:K-10
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-1794
Mailing Address - Country:US
Mailing Address - Phone:330-715-0119
Mailing Address - Fax:
Practice Address - Street 1:5940 SHAKERTOWN DR NW
Practice Address - Street 2:K-10
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-1794
Practice Address - Country:US
Practice Address - Phone:330-715-0119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-06
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH06720225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant