Provider Demographics
NPI:1083752836
Name:EAGLES, JENNIFER ANGELA (MPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANGELA
Last Name:EAGLES
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANGELA
Other - Last Name:BRESCIANI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3403 E MAIN ST
Mailing Address - Street 2:SPACE 2415
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-8683
Mailing Address - Country:US
Mailing Address - Phone:971-285-6292
Mailing Address - Fax:
Practice Address - Street 1:12124 HIGH TECH AVE
Practice Address - Street 2:STE 300
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-8373
Practice Address - Country:US
Practice Address - Phone:800-774-7785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1399225100000X
MN7854225100000X
OR5781225100000X
WAPT 60124585225100000X
TX1210320225100000X
AZ9758225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist