Provider Demographics
NPI:1346511490
Name:BRENNER, JACQUELYN TIFFANY (DPT)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:TIFFANY
Last Name:BRENNER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11808 MEADOW BRANCH DR APT 1128
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-5070
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4645 S CLYDE MORRIS BLVD STE 407
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-3005
Practice Address - Country:US
Practice Address - Phone:386-763-1771
Practice Address - Fax:386-763-3375
Is Sole Proprietor?:No
Enumeration Date:2012-01-21
Last Update Date:2012-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26059225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist