Provider Demographics
NPI:1104193101
Name:THEOS, JENNIFER J (PTA)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:J
Last Name:THEOS
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 1:13211 WHITEHAVEN LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1518
Mailing Address - Country:US
Mailing Address - Phone:239-247-3096
Mailing Address - Fax:
Practice Address - Street 1:1333 SANTA BARBARA BLVD
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-2803
Practice Address - Country:US
Practice Address - Phone:239-772-1333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21101225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant