Provider Demographics
NPI:1295383206
Name:EDER, JENA KAYE (PTA)
Entity Type:Individual
Prefix:
First Name:JENA
Middle Name:KAYE
Last Name:EDER
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 1:817 E COUNTY ROAD AA
Mailing Address - Street 2:
Mailing Address - City:LEOTI
Mailing Address - State:KS
Mailing Address - Zip Code:67861-6224
Mailing Address - Country:US
Mailing Address - Phone:252-508-3028
Mailing Address - Fax:
Practice Address - Street 1:817 E COUNTY ROAD AA
Practice Address - Street 2:
Practice Address - City:LEOTI
Practice Address - State:KS
Practice Address - Zip Code:67861-6224
Practice Address - Country:US
Practice Address - Phone:252-508-3028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA5242225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant