Provider Demographics
NPI:1073730222
Name:VAN GENT, JENNIFER MAY (RPT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MAY
Last Name:VAN GENT
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:SIM
Other - Last Name:VAN GENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPT
Mailing Address - Street 1:1084 FAIRFIELD MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33327-1812
Mailing Address - Country:US
Mailing Address - Phone:954-663-1647
Mailing Address - Fax:
Practice Address - Street 1:1084 FAIRFIELD MEADOWS DR
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33327-1812
Practice Address - Country:US
Practice Address - Phone:954-663-1647
Practice Address - Fax:954-756-7363
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21147225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAC085ZOtherMEDICARE FCSO