Provider Demographics
NPI:1104003151
Name:CARAWAN, JENNIFER MAUREEN (LPTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MAUREEN
Last Name:CARAWAN
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EATONTON
Mailing Address - State:GA
Mailing Address - Zip Code:31024-1141
Mailing Address - Country:US
Mailing Address - Phone:678-852-7474
Mailing Address - Fax:
Practice Address - Street 1:115 N JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-1019
Practice Address - Country:US
Practice Address - Phone:678-852-7474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602421225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant