Provider Demographics
NPI:1114978319
Name:JENNIFER H FORMAN MSPT PA
Entity Type:Organization
Organization Name:JENNIFER H FORMAN MSPT PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:FORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-289-4692
Mailing Address - Street 1:6860 NW 73RD STREET
Mailing Address - Street 2:
Mailing Address - City:PARKLAND
Mailing Address - State:FL
Mailing Address - Zip Code:33067-3916
Mailing Address - Country:US
Mailing Address - Phone:561-955-9384
Mailing Address - Fax:561-392-7395
Practice Address - Street 1:7134 BOCA POINTE DRIVE
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-3905
Practice Address - Country:US
Practice Address - Phone:561-955-9384
Practice Address - Fax:561-392-7395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLY911T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY911TOtherBLUE CROSS BLUE SHIELD
FLK6735Medicare ID - Type Unspecified