Provider Demographics
NPI:1093466658
Name:BANNER, JENNIFER E (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:BANNER
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 1:2244 LANGFORDVILLE RD
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:SC
Mailing Address - Zip Code:29936-3534
Mailing Address - Country:US
Mailing Address - Phone:423-608-2821
Mailing Address - Fax:
Practice Address - Street 1:2244 LANGFORDVILLE RD
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936-3534
Practice Address - Country:US
Practice Address - Phone:423-608-2821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2116225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant