Provider Demographics
NPI:1154818417
Name:MUYCO, JENNIFER SUNGA
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUNGA
Last Name:MUYCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CANYON VIEW DR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-6089
Mailing Address - Country:US
Mailing Address - Phone:678-986-7701
Mailing Address - Fax:
Practice Address - Street 1:201 CROSSTOWN DR
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3454
Practice Address - Country:US
Practice Address - Phone:770-632-5823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-21
Last Update Date:2018-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009598225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA056033895OtherDRIVERS LICENSE