Provider Demographics
NPI:1174004329
Name:WASHINGTON, JENNIFER M (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:M
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:WASHINGTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:17521 US HIGHWAY 69 S
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-5594
Mailing Address - Country:US
Mailing Address - Phone:903-839-3600
Mailing Address - Fax:
Practice Address - Street 1:5505 NEW COPELAND RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3955
Practice Address - Country:US
Practice Address - Phone:855-840-7257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-26
Last Update Date:2018-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2075603225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant