Provider Demographics
NPI:1164077764
Name:WHITE, JENNIFER J (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:WHITE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2002 JOHNSON ST STE 100
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-3640
Mailing Address - Country:US
Mailing Address - Phone:337-824-4547
Mailing Address - Fax:337-824-4548
Practice Address - Street 1:4501 JACKSON ST STE B
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2555
Practice Address - Country:US
Practice Address - Phone:318-704-0710
Practice Address - Fax:318-704-0711
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA8497225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant